Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
Grievance & Appeals Dispute Specialist
Summary of Job
Process disputes submitted by contracted and non-contracted providers. Types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI/ESMSEF appeals and Cotiviti disputes. Provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met. Perform administrative tasks related to the resolution and closures of grievances and appeals.
Responsibilities:
- Intake and preparation of Dispute Files for External Review:
- 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.
- Resolution of Disputes and Closure of Grievance and Appeals
- For disputes: receive and/or monitor reports and portals for dispute decisions; update all applicable systems and notify delegates as applicable; review decision to confirm accuracy and append to the system; document decisions in CAG and 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.
- For Grievances and Appeals: Perform administrative functions to close out Grievance and Appeal files; rout claims for adjustment; ensure validating adjustment was made correctly in accordance with the appeal decision; follow up with other business areas to ensure resolution actions were completed & document actions taken in CAG system.
- File Compliance
- 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 and resolution of final appeal and grievance actions.
- 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
- 1 – 2+ years’ relevant, professional work experience (Required)
- Additional experience/specialized training may be considered in lieu of educational requirements (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 receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
EmblemHealth may provide work visa sponsorship depending on factors such as business unit requirements, position nature, costs, and applicable laws and regulations.