Grievance Specialist- Remote

Healthfirst; Town of Florida (NY); Hybrid; USD 59,000 - 80,000; Full time

Job summary

Healthfirst is seeking a Grievance Specialist to join the Appeals & Grievances team. This fully remote role manages member- or authorized representative-initiated grievances across Healthfirst’s lines, from acknowledgment to investigation and written resolution letters, collaborating with internal departments to drive root-cause analysis and compliant resolutions.

The position emphasizes timely case documentation, adherence to NYS DOH/CMS requirements, and meeting production and quality metrics.

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.

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 to identify root causes and recommend appropriate resolutions.
• Partner with external vendors to ensure member issues involving subcontracted services are appropriately 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 and audit standards.
• Participate in department meetings, quality audits, training sessions, and performance reviews as needed.
• Meet department metrics for production and quality.

Skills

Microsoft Office

Excel

Word

PowerPoint

Outlook

Case tracking systems

Education

HS Diploma or GED

Bachelor’s degree preferred

Job description

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. **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).

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. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. 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

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.

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 affect 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.