Grievance Specialist- Remote

Healthfirst; Pennsylvania; Remote; USD 51.000 - 75.000; Vollzeit

Benefits dieser Stelle

Medical, dental, and vision coverage

401k contributions

Incentive and recognition programs

Zusammenfassung

Healthfirst is seeking a Grievance Specialist for the Appeals & Grievances team. This remote, non-clinical role handles member or authorized representative grievances across Medicare, Medicaid, CHPlus, SHP, QHP, EP, and CompleteCare, investigating concerns and delivering timely resolutions.

You will collaborate with Member Services, Provider Operations, Clinical, Enrollment, and Pharmacy, draft compliant resolution letters, maintain thorough case documentation, and meet quality metrics.

Qualifikationen

• HS Diploma or GED from an accredited institution.
• Understanding of utilization management processes and how service authorizations impact member access to care and claims payment
• Proficient in Microsoft Office Suite, including Excel (sort, track and filter trends), Word, PowerPoint, Outlook and 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 grievances or complaints resolution.
• Working knowledge of Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and/or Health Insurance Exchange (Marketplace/QHP) programs.
• Familiarity with applicable state and federal regulatory requirements, such as CMS regulations, the NYS Department of Health (DOH) Medicaid Managed Care Model Contract, and the Department of Financial Services (DFS).
• Experience with or knowledge of claims processing and provider billing workflows.
• Exposure to or direct experience with LTSS, including Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS).

Aufgaben

• Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters.
• Conduct detailed research by collaborating cross-functionally with internal departments to identify root causes and recommend appropriate resolutions.
• Partner with external vendors to ensure member issues involving subcontracted services and ancillary benefits are addressed and resolved.
• Draft and issue acknowledgement and resolution letters that are clear, and compliant with regulatory standards and timelines.
• Ensure timely and accurate case documentation in accordance with Healthfirst policies, regulatory requirements, and audit standards.
• Participate in department meetings, quality audits, training sessions, and performance reviews as needed.
• Meet department metrics for production and quality.

Kenntnisse

Utilization management understanding

Regulatory compliance knowledge

Cross-functional collaboration

Ausbildung

HS Diploma or GED

Bachelor’s degree or equivalent

Tools

Microsoft Office Suite

Case tracking systems

Jobbeschreibung

The Grievance Specialist is a member of the Appeals & Grievances (A&G) team at Healthfirst and is responsible for managing and resolving member or authorized representative–initiated grievances and complaints across Healthfirst’s product lines, including Medicare, Medicaid, Child Health Plus (CHPlus), Senior Health Partners (SHP), Commercial Qualified Health Plans (QHP), Essential Plans (EP), and CompleteCare. This is a non-clinical role focused exclusively on grievance and complaint resolution. The Specialist plays a key role in advocating for Healthfirst members by thoroughly investigating their concerns and ensuring timely, accurate, and compliant resolutions in accordance with regulatory requirements.

Work Location and Hours

• This position is 100% remote - Schedule M-F, 8am-4:30pm or 8:30am-5pm EST

Key Responsibilities

• Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters.
• Conduct detailed research by collaborating cross-functionally with internal departments (e.g., Member Services, Provider Operations, Clinical, Enrollment, Pharmacy) to identify root causes and recommend appropriate resolutions.
• Partner with external vendors (e.g., DentaQuest, EyeMed, Logisticare vendors) to ensure member issues involving subcontracted services and ancillary benefits are appropriately addressed and resolved.
• Draft and issue acknowledgement and resolution letters that are clear, and compliant with regulatory standards and timelines (e.g., NYS DOH, CMS, Medicaid Managed Care Model Contract).
• Ensure timely and accurate case documentation in accordance with Healthfirst policies, regulatory requirements, and audit standards.
• Participate in department meetings, quality audits, training sessions, in-person quarterly town halls and performance reviews as needed.
• Meet department metrics for production and quality.

Minimum Qualifications

• HS Diploma or GED from an accredited institution.
• Understanding of utilization management processes and how service authorizations impact member access to care and claims payment
• Proficient in Microsoft Office Suite, including Excel (sort, track and filter trends), Word, PowerPoint, Outlook and case tracking systems.

Preferred Qualifications

• 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 grievances or complaints resolution.
• Working knowledge of Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and/or Health Insurance Exchange (Marketplace/QHP) programs.
• Familiarity with applicable state and federal regulatory requirements, such as CMS regulations, the NYS Department of Health (DOH) Medicaid Managed Care Model Contract, and the Department of Financial Services (DFS).
• Experience with or knowledge of claims processing and provider billing workflows.
• Exposure to or direct experience with long-term services and supports (LTSS), including Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS).

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

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

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.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.