Grievance & Appeals Specialist 

We are seeking a talented Grievance & Appeals Specialist who will be responsible for responding to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations. They will process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; and ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards. This individual will work as an effective interface between internal and external customers and maintain good member and provider relations
 
Responsibilities: 

  • Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
  • Provide written acknowledgment of member and provider correspondence.
  • Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member’s complaint or appeal.
  • Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
  • Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases.
  • Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
  • Follow-up with responsible departments and delegated entities to ensure compliance.
  • Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
  • Monitor daily and weekly pending reports and personal worklists, ensuring internal & regulatory timeframes are met.
  • Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE.
  • Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
  • Prepare written responses to all member and provider correspondence that appropriately address each complainant’s issues and are structurally accurate.
  • Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
  • Perform other duties as assigned or required.
  • Regular attendance is an essential function of the job.

Qualifications:

  •  Associate Degree in a related field; Bachelor’s preferred
  • 3+ years of related professional work experience required
  • Additional years of experience/training may be considered in lieu of educational requirements required
  • Excellent verbal and written communications skills required
  • Ability to comprehend and produce grammatically accurate, error-free business correspondence required
  • Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required
  • Excellent problem solving and analytical skills required
  • Ability to work under pressure and deliver complete, accurate, and timely results required
  • Excellent organization and time management skills required
  • Customer service experience preferred
  • Excellent product knowledge preferred
  • Prior health industry and/or compliance work experience preferred
  • Experience in a managed care/compliance environment preferred

Additional Information

  • Requisition ID: 1000001393
  • Hiring Range: $45,000-$77,000

Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

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