Remote Grievance Resolution Specialist

Healthfirst; Pennsylvania; Remote; USD 51,000 - 75,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401k contributions

Incentive and recognition programs

Job summary

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.

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.
• 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).

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 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.

Skills

Utilization management understanding

Regulatory compliance knowledge

Cross-functional collaboration

Education

HS Diploma or GED

Bachelor’s degree or equivalent

Tools

Microsoft Office Suite

Case tracking systems

Job description

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.