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 & Appeals Audit & Project Lead
🔍 New York, New York
Summary of Job
Coordinate all phases of Grievance and Appeal regulatory and accreditation audits including universe generation and case file compilation, during which all submissions are quality checked and risks are identified and mitigated to the extent possible. Serve as subject matter expert (SME) and liaison between business partners such as IT, Legal, Compliance. Analyze current processes against new regulations/requirements; make determinations on needed changes; collaborate with Leader and other department leadership and stakeholders to drive all necessary changes. Support the G&A Systems & Project Leader as a G&A systems (CAG) SME, responsible for submission and tracking of support tickets, conducting UAT and troubleshooting issues.
Responsibilities:
- Responsible for the fulfillment of G&A universe requests, including holistic validation, logic checks and quality review of all data elements.
Interact with, respond to, and present to regulatory and accreditation auditors. - Drive development of responses, through engagement with the G&A team, to any findings or requests for information, conducting applicable impact analysis and providing responses to regulatory and accreditation audit requests, meeting all deadlines. Ensure that all responses meet quality guidelines for completeness, accuracy, and timeliness.
- Letter administrator, responsible for development and programming of letter content, ensuring minimal manual updates to letters are requirement by G&A staff, thereby reducing risk of errors and increasing productivity.
- Responsible for continuous improvement of letter templates, implementing changes based on feedback and needs of the team.
- Provide expertise and vision with respect to planning, development and execution of G&A projects and implementations.
- Oversee/evaluate team activities and functions to ensure success and achievement of financial and timeline targets.
- Manage resources and priorities, risk mitigation, metric management, analysis, contingency planning, and reporting.
- Maintain solid knowledge and understanding of G&A processes and requirements to ensure projects are implemented appropriately and risks to the business are mitigated.
- Support G&A team to troubleshoot system issues, escalating to vendor as appropriate.
- Submit support desk tickets ad track progress/completion, monitoring monthly support hour usage.
- Identify technology-based pain points and drive solutioning, increasing employee satisfaction by ensuring they have the optimal tools to complete job functions.
- Conduct UAT testing on a quarterly and/or ad-hoc basis to ensure business processes are behaving as intended and there is no impact to operations as a result of IT releases.
Qualifications:
- BS or BA degree
- Project Management (PMI) certification or Six Sigma/related certification or training preferred
- 5 – 8+ years of relevant experience in Operations, preferably in a healthcare environment (Required)
- 3+ years of experience in grievance and appeals or related function (Preferred)
- Additional experience/specialized training/certification(s) may be considered in lieu of BS/BA degree (Required)
- 3+ years of audit experience (Preferred)
- Energy, drive and passion for end-to-end excellence and improvement (Required)
- Strong problem-solving and analytical skills that can be applied across all types of business problems (Required)
- Strong communications skills (verbal, written, presentation, facilitation, interpersonal) with all types/levels of audiences (Required)
- Excellent collaboration skills and the ability to influence management decisions (Required)
- Proficient in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) (Required)
- Ability to lead/manage multiple projects and cross-functional teams simultaneously (Required)
- Ability to clearly define and articulate project goals and objectives, and to measure outcomes (Required)
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.