Grievance & Appeals Quality Assurance Specialist

VNS Health; New York (NY); Hybrid; USD 70,000 - 88,000; Full time

Benefits offered by this job

Referral bonuses

Generous PTO

Health insurance

Retirement matching

Wellness programs

FSAs

Tuition reimbursement

Career advancement

Internal mobility

Job summary

VNS Health in New York, NY, is seeking an experienced Grievance & Appeals Quality Analyst to identify and resolve operational quality problems within the G&A department. You will conduct daily reviews of case files, letters, and database records to ensure compliance with plans, regulatory requirements, and business practices under supervision.

In this hybrid role, you will coach staff, analyze audit results, develop remediation plans, and produce performance reports.

Qualifications

• Bachelor's degree in health care administration, human services, business administration, or related discipline or equivalent work experience.
• Minimum four years professional experience in health care, including at least two years in grievance and appeals in a managed care setting.
• Excellent verbal and written communication skills.
• Proficient computer skills including Microsoft Office (Word and Excel) and database software.

Responsibilities

• Participate and maintain current knowledge of state and federal regulatory and contractual requirements related to grievances and appeals for Medicare and Medicaid managed care.
• Conduct daily detailed quality reviews of G&A caseload, including records, folders, and documentation; provide feedback and identify trends.
• Identify and assist with challenging cases with potential impact on compliance and plan priorities.
• Coach staff on urgent issues and escalate as appropriate.
• Work with Education to update training documents and conduct training for new hires and existing staff.
• Collaborate to identify training needs and develop curriculum; evaluate effectiveness and revise materials.

Skills

Verbal and written communication

Education

Bachelor's Degree in health care administration

Tools

Microsoft Office (Word & Excel)

Database software

Job description

VNS Health in New York, NY, is seeking an experienced Grievance & Appeals Quality Analyst to identify and resolve operational quality problems within the G&A department. You will conduct daily reviews of case files, letters, and database records to ensure compliance with plans, regulatory requirements, and business practices under supervision.

In this hybrid role, you will coach staff, analyze audit results, develop remediation plans, and produce performance reports.