Appeals and Grievances Clinical Specialist

HealthFirst

11d•Remote

About The Position

Position Summary: The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers. This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy). 100% Remote - Work Schedule for this Role will be Wed-Sat from 7am-5:30pm. (4X10) Schedule.

Requirements

RN , LPN OR Dental Hygienist

Nice To Haves

Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess).
Experience with care management systems, such as CCMS, TruCare and Hyland.
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Responsibilities

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services.
The end to end process requires the Specialist to independently: Research issues Reference and understand HF’s internal health plans policies and procedures to frame decisions Interpret regulations Resolve cases and make critical decisions Update file documentation such as the file notes and case summary Manage all duties within regulatory timeframes Communicate effectively to hand-off and pick-up work from colleagues Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
Additional duties as assigned