Manager, Clinical Appeals & Grievances

HealthFirst; United States; Remote; USD 103,000 - 149,000; Full time

Benefits offered by this job

Medical, Dental & Vision Coverage

Life Insurance

401k Contributions

Job summary

Healthfirst is seeking a Weekend Inventory Manager for Appeals & Grievances to oversee weekend inventory and assignments for the A&G Clinical Specialist team. This full-time role requires weekend availability (Fri-Mon or Thurs-Sun) and a four-day schedule.

You will collaborate with leaders to drive production, quality and regulatory compliance, balancing strategic priorities with staffing needs to support Healthfirst's growth and profitability goals.

Qualifications

• H.S. Diploma or GED required.
• Experience with appeals and grievances or healthcare setting.
• Strong verbal and written communication.
• Ability to handle multiple priorities and work independently.
• Weekend schedule availability (Fri-Mon or Thurs-Sun).
• Proficiency with Word, Excel, email, and care management systems (CCMS, TruCare, Hyland).

Responsibilities

• Prepare and plan weekend staff assignments to ensure compliance.
• Triage and assign expedited appeals and optimize routing.
• Manage inventory to ensure regulatory compliance for weekend appeals.
• Communicate and escalate cases to Medical Peer reviewers.
• Maintain vendor relationships and monitor performance and compliance.
• Coordinate with outside departments for escalation and collaboration.
• Oversee letter review and printing and coordinate with the mailroom.
• Review change requests and follow-up routing.
• Submit Level 2 appeals packets to the appropriate entity.
• Stay updated on industry trends and best practices.
• Identify trends and recommend improvements.
• Build partnerships across operations to improve responsiveness.
• Provide feedback to leadership on staff performance.
• Comply with HIPAA and maintain confidentiality.
• Adhere to state and federal guidelines.
• Perform additional duties as assigned.

Skills

Verbal communication

Written communication

Fast-paced environment

Multitasking

Weekend availability

Education

H.S. Diploma or GED

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Microsoft Word

Excel

Job description

The Appeals & Grievances (A&G) Weekend Inventory Manager is responsible for managing and monitoring appeal inventory for a team of A&G Clinical Specialist. This is a full-time role, expected to work 4 days a week and must be able to work the weekends (i.e. Fri-Mon or Thurs-Sun). The incumbent works closely with multiple leaders in the organization to monitor and drive internal and external production teams to ensure consistent output, high quality and to maintain compliance on all levels. The Weekend Inventory Manager will utilize strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

Duties & Responsibilities:

• Prepare and plan the weekend staff’s assignments and volume to ensure compliance
• Triage and assign expedited appeals while helping standardize and optimize how Appeals and Grievances are routed
• Manage inventory to ensure regulatory compliance for appeals processed through the weekend
• Communicate and escape cases to Medical Peer reviewers
• Maintain delegated vendor relationships and ensure vendor performance and compliance measures are met
• Coordinate with outside departments for case escalation, clarifications and collaboration needed for appeal resolution
• Manage letter review and printing and coordinate with the mailroom for expedited printing needs
• Review case change requests and cancellations including appropriate routing for follow up
• Review and submit Level 2 appeals packets to the appropriate entity
• Maintain knowledge of industry trends, best practices and protocols and share with other units comprising the enterprise to ensure general consistencies and enhancements
• Identify trends and recommend solutions for improvement
• Maintain best practices and strategically deploy approaches to meet production, compliance and quality targets to perform all Appeals & Grievances tasks
• Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
• Provide feedback and recommendations to leadership concerning staff performance
• Comply with HIPAA guidelines and maintain confidentiality of member, provider, medical and departmental information.
• Adhere to state and federal compliance and regulatory guidelines
• Additional duties as assigned

Minimum Qualifications:

• H.S. Diploma or GED
• Proven work experience with appeals and grievances or a healthcare environment
• Work experience demonstrating verbal and written communication skills
• Experience working independently in a fast-paced environment that requires handling multiple priorities simultaneously
• Willing and able to work a weekend schedule (i.e. Fri-Mon or Thurs-Sun)
• Work experience using several computer applications such as Microsoft Word and Excel, corporate email and virtual filing systems (ie. Macess), and experience with care management systems, such as CCMS, TruCare and Hyland.

Preferred Qualifications:

• Bachelor’s degree
• RN or LPN strongly preferred
• Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guideline

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.

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): $103,400 - $149,430
• All Other Locations (within approved locations): $88,700 - $131,920

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.