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
Summary of Position
We are seeking a talented Grievance & Appeals Specialist who will be responsible for responding to written/verbal grievances, complaints, appeals, and disputes submitted by members and providers in accordance with NCQA, CMS, State, and other regulations. They will process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; and ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards. This individual will work as an effective interface between internal and external customers and maintain good member and provider relations.
Responsibilities:
- Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
- Provide written acknowledgment of member and provider correspondence.
- Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint or appeal.
- 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.
- Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
- 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 & regulatory timeframes are met.
- Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE.
- Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
- Prepare written responses to all member and provider correspondence that appropriately address each complainant’s issues and are structurally accurate.
- Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
- Perform other duties as assigned or required.
- Regular attendance is an essential function of the job.
Qualifications:
- Associate Degree in a related field; Bachelor’s preferred
- 3+ years of related professional work experience required
- Additional years of experience/training may be considered in lieu of educational requirements required
- Excellent verbal and written communications skills required
- Ability to comprehend and produce grammatically accurate, error-free business correspondence required
- Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required
- 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
- Customer service experience preferred
- Excellent product knowledge preferred
- Prior health industry and/or compliance work experience preferred
- Experience in a managed care/compliance environment preferred
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.