Hybrid Paralegal II - ESH Quality Appeals & Grievances (Bronx Office & Work From Home)

CareSource•New York, NY

22d•$54,500 - $87,300•Hybrid

About The Position

The Paralegal II - Quality Appeals & Grievances provides legal, analytical, and operational support to the Quality Appeals and Grievances function. The role conducts research, reviews appeal and grievance determinations, analyzes external review outcomes, prepares reports, and supports regulatory compliance activities. The Paralegal I assists with drafting responses, auditing appeal documentation, and providing insights to support quality improvement and regulatory readiness under the guidance of department leadership.

Requirements

High School or GED required
Two (2) years paralegal, legal support, managed care, healthcare compliance, appeals, grievances, or related experience required
Proficiency in Microsoft Office Suite, including Word, Excel, PowerPoint, and other business applications
Working knowledge of legal research tools, regulatory resources, and industry guidance applicable to appeals, grievances, external reviews, and fair hearings
Knowledge of applicable healthcare regulations, regulatory requirements, accreditation standards, and organizational policies related to appeals and grievances
Working knowledge of managed care, healthcare operations, and appeals and grievance processes
Strong analytical, critical thinking, and research skills with the ability to evaluate complex information, identify trends, and develop meaningful insights
Ability to conduct quality assurance reviews, audits, and compliance monitoring activities to ensure accuracy, consistency, and regulatory compliance
Ability to collect, analyze, interpret, and present data to support reporting, decision-making, quality improvement, and operational objectives
Strong written and verbal communication skills with the ability to prepare reports, correspondence, rebuttals, and other business documentation
Demonstrated customer service focus and ability to build collaborative working relationships with internal and external stakeholders
Strong organizational skills with the ability to manage multiple priorities, meet deadlines, and maintain attention to detail in a fast-paced environment
Ability to utilize approved technology and AI-enabled tools to improve efficiency, accuracy, and overall work outcomes
Ability to work independently within established guidelines, exercise sound judgment, and accept constructive feedback
Paralegal Certificate required

Nice To Haves

Associates degree preferred

Responsibilities

Provide paralegal, research, and administrative support to Quality Appeals & Grievances leadership and team members.
Respond to internal and external inquiries as directed, with appropriate review and oversight.
Initiate, gather, and analyze information related to internal appeal decisions.
Conduct research utilizing legal databases, regulatory guidance, industry resources, and approved organizational technologies to support appeal determinations and rebuttal preparation.
Research, analyze, and support the preparation of responses, documentation, and supporting records related to External Reviews, Fair Hearings, audits, and regulatory inquiries.
Analyze internal and external appeal outcomes, identify trends, and prepare reports and dashboards related to case volume, overturn rates, review findings, reviewer qualifications, and other key performance indicators.
Develop and deliver weekly, monthly, and quarterly reports based on appeal and review data.
Audit Final Adverse Determination (FAD) letters and other appeal and grievance determinations to ensure regulatory compliance and quality standards are met.
Identify trends, risks, and opportunities for process improvement and communicate findings to department leadership.
Provide feedback to the Clinical Coordinator and department leadership as directed.
Perform administrative duties as delegated by the department head.
Assist with departmental initiatives and special projects as assigned.
Perform any other job related duties as requested.