Remote Grievance & Appeals Specialist

Healthfirst; Connecticut; A distancia; USD 51.000 - 80.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical benefits

Dental and vision coverage

401k contributions

Descripción de la vacante

Healthfirst seeks a Grievance Specialist to join the Appeals & Grievances team. This is a 100% remote, non-clinical role focused on resolving member grievances across Medicare, Medicaid, CHPlus, SHP, QHP, EP, and CompleteCare.

The Specialist will independently manage a full case lifecycle, collaborate with Healthfirst departments and external vendors, and ensure timely, accurate resolutions in compliance with regulatory standards.

Formación

• 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.

Responsabilidades

• 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 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.

Conocimientos

MS Office

Excel

Word

PowerPoint

Outlook

Case tracking systems

Data research

Educación

HS Diploma or GED

Bachelor’s degree or equivalent

Herramientas

Case tracking software

Descripción del empleo

Healthfirst seeks a Grievance Specialist to join the Appeals & Grievances team. This is a 100% remote, non-clinical role focused on resolving member grievances across Medicare, Medicaid, CHPlus, SHP, QHP, EP, and CompleteCare.

The Specialist will independently manage a full case lifecycle, collaborate with Healthfirst departments and external vendors, and ensure timely, accurate resolutions in compliance with regulatory standards.