Grievance Specialist
H
HealthfirstManaged care
Source API remote eligibility restrictions: United States, 8am-4:30pm or 8:30am-5pm ESTFull-TimeJunior
Salary51,000 - 74,880 USD per year
Apply NowOpens the employer's application page
Job Details
- Experience
- 2+ years of experience in managed care, member services, or healthcare grievances or complaints resolution.
- Required Skills
- Microsoft ExcelMicrosoft OfficePowerPoint
Requirements
- Have a high school diploma or GED from an accredited institution.
- Understand utilization management processes and how service authorizations affect member access to care and claims payment.
- Be proficient in Microsoft Office Suite, including Excel, Word, PowerPoint, and Outlook.
- Be proficient with case tracking systems.
- Bachelor’s degree or equivalent experience in healthcare, public health, or a related field preferred.
- 2+ years of experience in managed care, member services, or healthcare grievance or complaint resolution preferred.
- Have working knowledge of Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and/or Health Insurance Exchange programs preferred.
- Be familiar with applicable state and federal regulations, including CMS regulations, the NYS DOH Medicaid Managed Care Model Contract, and DFS requirements preferred.
- Experience or knowledge of claims processing and provider billing workflows preferred.
- Exposure to or direct experience with LTSS, including PCS and CDPAS, preferred.
Responsibilities
- Manage a caseload of grievances through acknowledgement, investigation, resolution, and written member resolution letters.
- Research member concerns with internal departments, including Member Services, Provider Operations, Clinical, Enrollment, and Pharmacy.
- Partner with external vendors to address and resolve issues involving subcontracted services and ancillary benefits.
- Draft and issue acknowledgement and resolution letters that meet regulatory standards and timelines.
- Document cases accurately in accordance with company policies, regulatory requirements, and audit standards.
- Participate in department meetings, quality audits, training sessions, quarterly town halls, and performance reviews as needed.
- Meet department production and quality metrics.
View Full Description & ApplyYou'll be redirected to the employer's site
