Appeals Specialist - Remote

Healthfirst; New York (NY); Hybrid; USD 51,000 - 80,000; Full time

Benefits offered by this job

Health insurance

Dental and vision coverage

401k plan

Job summary

Healthfirst is seeking an Appeals Specialist for a 100% remote role, Monday through Friday, 8am-5pm EST or 8:30am-5pm EST. You will manage non-clinical case development and ensure compliance with Federal and State regulations while handling a personal caseload of member and provider appeals.

Responsibilities include researching issues, interpreting payer policies, and resolving denials within regulatory timeframes. Strong attention to detail and the ability to work independently are essential.

Qualifications

• Minimum of two (2) years of work experience in Managed Care Health Insurance Plan.
• Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial plans end to end.
• HS Diploma or GED from an accredited institution; Bachelor’s degree preferred.
• Claims processing experience with coding criteria is preferred.

Responsibilities

• Research issues and frame decisions.
• Interpret regulations and reference internal health plans’ policies.
• Resolve cases and make critical decisions.
• Edit and finalize resolution letters within regulatory timeframes.
• Identify patterns or trends in denials for process improvement.
• Prepare and submit well documented appeals per payer guidelines.

Skills

Critical thinking

Detail oriented

Time management

Education

HS Diploma or GED

Bachelor’s degree or relevant work experience

Job description

The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF’s line of businesses which include commercial, Medicaid, dual enrollments, Medicare and complete care. This position is 100% Remote M-F, 8am-5pm or 8:30pm-5pm EST. Appeals Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and is accountable for investigating and resolving member or non-contracted provider-initiated cases.

Key Responsibilities

• Research issues
• Reference and understand HF’s internal health plans’ policies and procedures to frame decisions
• Interpret regulations
• Resolve cases and make critical decisions
• Edit and finalize resolution letters
• Manage all duties within regulatory timeframes
• Communicate effectively to hand-off or pick-up work from colleagues
• Work within a framework that measures productivity and quality for each Specialist against expectations
• Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes
• Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits
• Identify patterns or trends in denials and provide feedback for leadership for process improvement
• Remain up to date on payer polices, industry regulations and coding updates to ensure compliance and maximize reimbursement
• Additional duties as assigned

Minimum Qualification

• HS Diploma or GED from an accredited institution
• Minimum of two (2) years of work experience in Managed Care Health Insurance Plan
• Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end.
• Claims processing experience with coding criteria is preferred.
• This includes the auto forwarding of upheld cases to the respective regulatory independent reviewer for denied cases.

Preferred Qualifications

• Bachelor’s degree from an accredited institution or relevant work experience
• Demonstrated critical thinking and decision-making competencies
• Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [e-mail] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying.

Thank you for considering a career with HF Management Services, LLC.

Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070
• All Other Locations (within approved locations): $51,000 - $74,880

• In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office.

The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country.

So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you.