Appeals and Grievances Specialist, Non Clinical, Lake Mary, FL

Employer Healthfirst Inc.
Created 06/09/2021
Reference 1079684
Job type Full Time
State FL
City Lake Mary
The A&G Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The A&G Specialist will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases.

Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle non-clinical claim appeals that come from Healthfirst participating and non-participating providers.

Duties and Responsibilities
  • Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end to end process requires the Specialist to independently:
    • Research issues
    • Reference and understand HF's internal health plans' policies and procedures to frame decisions
    • Interpret regulations
    • Resolve cases and make critical decisions
    • Edit and finalize resolution letters
    • Manage all duties within regulatory time-frames
    • Communicate effectively to hand-off or pick-up work from colleagues
    • Work within a framework that measures productivity and quality for each Specialist against expectations
    • Additional duties as assigned

Minimum Qualifications
  • Bachelor's degree from an accredited institution or relevant work experience


Preferred Qualifications
  • Minimum of two (2) years of work experience in Managed Care or Health Insurance
  • Work experience in claims, customer service, home health, hospital or doctor's office preferred
  • Experience working in care management systems, such as CCMS, TruCare or Hyland
  • Demonstrated critical thinking and decision-making competencies
  • Highly effective communication, organizational, and customer service skills
  • Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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 careers@Healthfirst.org 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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

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.

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