Appeals & Grievances Clinical Coordinator

🔥 19 hours ago

🗽 New York – Remote

🗽 New York – Remote

💵 $42.2k - $62.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

📋 Description

• Support the clinical team to ensure timely and accurate processing of cases • Set up case files for clinical review • Conduct appeal research and filing, including organizational determination research • Request member medical records and organize documentation • Prepare written summaries and schedule cases • Process case reviews and document appeal resolutions • Send complete case files to external review organizations as required by regulatory guidelines • Prepare cases by gathering documentation, loading evidence, and making calls to members and providers • Generate and print determination and authorization notification letters • Complete data entry and authorization creation in the True care system • Notify the team lead of appeal patterns, claim errors, configuration issues, and systemic problems • Liaise with providers and members during appeal processing • Collaborate with Contact Center Operations, Claims, DSE, and E&B • Ensure appeals and grievances are processed within New York State and federal timeframes • Prepare evidence packages and draft letters • Request denial files from delegated vendors and prepare cases for Clinical Specialist reviews • Maintain file integrity, content, and confidentiality • Participate in meetings and perform additional duties as assigned

🎯 Requirements

• HS Diploma or GED • Knowledge of related NY state and federal regulations highly desirable • Proficiency in Microsoft Office required • Knowledge of the New York state ART 44 PHL and federal regulatory environment • Knowledge of claims payment process and claims data system (MHS) • Ability to work both independently and as a team member • Demonstrated ability to be deadline focused and flexible in order to adjust to priority changes

🏖️ Benefits

• Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Competitive compensation and benefits package

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