Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Expedited Appeals Specialist (Weekends Included) - Remote

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Operations
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EmblemHealth
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Summary

We are seeking a dynamic Expedited Appeals Specialist responsible for processing expedited appeals: those that are complex, require multiple hand-offs, and tend to have extremely tight deadlines. This individual will ensure accuracy and compliance within the constraints of extremely quick turnaround times. The Expedited Appeals Specialist will also perform end-to-end G&A processing; consistently operate in a fast-paced high-pressure environment and monitor all aspects of the G&A process; ensure that members have appropriate access to care. Due to regulatory requirements and turn-around times of the Expedited Appeal unit, the Specialists are required to work weekends and holidays as the organization must maintain expedited appeal coverage 7 days a week, 365 days a year. 

Roles and Responsibilities

  • Independently perform triage function: review and evaluate appeal requests; identify and classify member and provider appeals. Using internal systems, determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
  • Provide verbal and written member and provider correspondence as needed for authorized representative or needed clinical information.
  • Conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc., as applicable.
  • Make critical decisions regarding research and investigation to appropriately resolve all inquiries; prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the Plan’s determination; make recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit and contract materials; present findings and recommendations to appropriate parties for sign-off.
  • Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely authorization effectuation and resolution of cases.
  • Perform necessary follow-up with responsible departments and delegated entities to ensure compliance.
  • Monitor hourly and daily pending reports and personal worklists, ensuring adherence to CMS, NCQA, DOH, NYS, Connecticut and Massachusetts regulatory requirements, as well as operational SLAs and department performance standards, thereby ensuring members’ access to care.
  • Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant’s issue(s) and are structurally accurate. Responsible for ensuring responses are completed within the applicable regulatory timeframe.
  • Complete submission of case files and responses to entities such as DFS, DOH, AG and Maximus; ensure timely and appropriate response submissions.
  • Document final resolutions along with all required data to facilitate accurate reporting, tracking, and trending.
  • Identify workflow improvements and work with the team to recommend and implement change(s).
  • Provide recommendations to management regarding issue resolution, root cause analysis and best practices.
  • Serve as a point of escalation for problems, providing guidance and expertise to team members as well as helping to identify and address core business requirements.
  • May train, guide, and mentor new G&A Specialists.
  • Serve as a coach and mentor to the associates providing support and guidance in complex situations.
  • Maintain acceptable attendance standard with minimal unscheduled PTO.
  • Exceed median production and compliance standards for both case resolution and data requirements.
  • Perform other duties as directed, assigned, or required.

Qualifications

  • Bachelors’ degree
  • Additional related experience/specialized training may be considered in lieu of degree requirements
  • 3 – 5+ years of related experience, preferably in the health industry and/or area of compliance required
  • Extensive knowledge and experience in claims, enrollment, benefits, and member contracts required
  • Ability to mentor specialists and to provide assistance on complex cases required
  • Must be well versed in all aspects of the complaint, grievance and appeal process and be able to process all types of correspondence handled by Grievance and Appeals required
  • Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) required
  • Excellent product knowledge required
  • Excellent prioritizing, organizing, time management, problem solving and analytical skills required
  • Ability to work under pressure and deliver complete, accurate, and timely results required
  • Leadership skills preferred

Security Disclosure

If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.

 

We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail. 

Pay Disclosure

A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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