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 Dispute Specialist
Summary of Position
We are seeking a dynamic Grievance and Appeals Dispute Specialist who will be responsible for processing disputes submitted by contracted and non-contracted providers. The types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI/ESMSEF appeals and Cotiviti disputes. This individual will provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.
Roles and Responsibilities:
- Facilitate the dispute review: submit appeal packet via UPS or dispute agent portal, as applicable.
- For Contracted Facility Dispute Resolution Agent (DRA) requests, provide email notification to the contacted facility, notifying them that the request has been submitted to the DRA.
- Intake disputes and compile “dispute” packets for submission to either the DRA agent or Cotiviti
- Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid.
- Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet.
- Receive dispute decision, updating all applicable systems and notifying delegates as applicable
- Monitor email and the dispute agent portal for decisions
- Review decision to confirm accuracy and append to the system
- Document decisions in CAG; notify the Sr. Medical Clerk (SMC) to update the care management system as applicable.
- For delegate cases, notify the applicable delegate of the decision via email.
- If decision is overturned, the Dispute Specialist will reach out to claims to facilitate the effectuation of the decision.
- Ensure timeframes are met and files are completed per G&A operational policies and procedures.
- Monitor daily and weekly pending reports and CAG work list to ensure timely submission of files.
- Classify/code CAG inquiries appropriately, entering all actions taken in investigation for auditing & reporting purposes.
- Make follow-up calls to provider or reach out to the dispute agent via email for any additional information
- Liaison with Claims to ensure determinations are effectuated within stringent timeframes.
- Regular attendance is an essential function of the job.
- Perform other duties as assigned or required.
Qualifications:
- Associates degree
- Additional experience/specialized training may be considered in lieu of educational requirements required
- 1 – 2+ years’ relevant, professional work experience required
- Ability to work under pressure and deliver accurate and timely results required
- Excellent communications skills (verbal, written, interpersonal) required
- Working knowledge of Health Insurance processes required
- Proficient with MS Office (Word, Excel, Powerpoint, Teams, Outlook, etc.) required
- Excellent organizational, problem solving and analytical skills 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.