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.

Grievance and Appeals Specialist

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Manager & Professional
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190O8 Requisition #
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Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, NY State and other regulations.  Types of correspondence handled by the individual will include, but is not limited to, correspondence, payment disputes, complaints/grievances, and appeals.  Work requires exercising considerable independent judgment and initiative in performing case file investigation.  The financial consequences of an error could be significant.  Reviews complex cases.  Has extensive knowledge and experience in claims, benefits and member contracts.

Responsibilities:
  • Provide written acknowledgment of all member and provider correspondence.  
  • Independently review all receipts; interpret regulations and appropriately classify the inquiry.  
  • Make critical decisions regarding research and investigation to appropriately categorize and resolve all inquiries.  
  • Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.  
  • Facilitate the investigation of complex cases presented by members and providers.
  • Provide recommendations to management on cost saving opportunities, best practices and performance issues.
  • Assist the Manager/Supervisor in developing workflows and process efficiencies.  
  • Prepare written responses to all member and provider correspondence that appropriately addresses each complainant’s issues and are structurally accurate.
  • Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases.
  • Monitor daily and weekly pending reports and personal SAWS worklists; make necessary follow-up calls to internal and external entities to ensure that cases are completed within the applicable timeframe.  
  • Liaise with Claims to ensure determinations are effectuated within stringent timeframes.  
  • Classify and code ESaws inquiries appropriately; document actions taken in investigation for auditing and reporting.  
  • Prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.
Qualifications:
  • Bachelor’s Degree 
  • Additional years of related experience may be used in place of educational requirements
  • 2 – 3 years of work experience in a related field required
  • Experience in a managed care/compliance environment preferred
  • Experience in comprehending and producing business correspondence required
  • Working knowledge of workflow processes required
  • Customer service experience desirable preferred
  • Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required

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, 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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