Manager, Clinical Appeals & Grievances

🔥 2 minutes ago

🇺🇸 United States – Remote

💵 $88.7k - $131.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Prepare and plan weekend staff assignments and volume to ensure compliance • Triage and assign expedited appeals • Standardize and optimize Appeals and Grievances routing • Manage weekend appeal inventory to ensure regulatory compliance • Communicate and escalate cases to Medical Peer reviewers • Maintain delegated vendor relationships and monitor vendor performance and compliance • Coordinate with outside departments on escalations, clarifications and appeal resolution • Manage letter review and printing and coordinate expedited printing with the mailroom • Review case change requests and cancellations and route follow-up appropriately • Review and submit Level 2 appeals packets to the appropriate entity • Maintain knowledge of industry trends, best practices and protocols • Identify trends and recommend improvement solutions • Deploy approaches to meet production, compliance and quality targets • Build partnerships across and outside operations • Provide feedback and recommendations to leadership on staff performance • Maintain confidentiality of member, provider, medical and departmental information • Perform additional duties as assigned

🎯 Requirements

• H.S. Diploma or GED • Proven work experience with appeals and grievances or a healthcare environment • Work experience demonstrating verbal and written communication skills • Experience working independently in a fast-paced environment that requires handling multiple priorities simultaneously • Willing and able to work a weekend schedule (Fri-Mon or Thurs-Sun) • Experience using Microsoft Word and Excel, corporate email and virtual filing systems such as Macess • Experience with care management systems such as CCMS, TruCare and Hyland • Bachelor’s degree preferred • RN or LPN strongly preferred • Experience in clinical practice with experience in appeals and grievances, claims processing, utilization review or utilization management/case management preferred • Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL, InterQual, Milliman or Medicare local coverage guidelines preferred • Must comply with HIPAA, state and federal compliance, and regulatory guidelines

🏖️ Benefits

• Medical, dental and vision coverage (subject to eligibility requirements) • Incentive and recognition programs • Life insurance (subject to eligibility requirements) • 401k contributions (subject to eligibility requirements) • Competitive compensation and benefits package