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 Specialist

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Manager & Professional
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2103L 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 judgment and initiative in performing case file investigation.  Position requires knowledge and experience in claims, enrollment, benefits and member contracts.

Responsibilities:

  • Review and evaluate appeal and grievance requests to 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 written acknowledgment of member and provider correspondence.  
  • 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.  
  • Serve as liaison with EmblemHealth departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases.
  • Follow-up with responsible departments and delegated entities to ensure compliance.
  • Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
  • Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
  • Provide recommendations to management regarding issue resolution and best practices. 
  • Prepare written responses to all member and provider correspondence that appropriately address each complainant’s issues and are structurally accurate.
  • Document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.
     

Requirements:

  • Associates degree required, in a related field. Bachelor's degree preferred
  • Minimum 3 years of related experience is required; health industry and/or compliance work experience preferred 
  • Excellent verbal and written skills required
  • Experience in a managed care/compliance environment preferred
  • Experience in comprehending and producing grammatically accurate and error-free business correspondence required
  • Customer service experience preferred
  • Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required
  • Excellent product knowledge preferred
  • Excellent problem solving and analytical skills required
  • Ability to work under pressure and deliver complete, accurate, and timely results required
  • Excellent organization and time management skills 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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