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.

Sr. Grievance & Appeals Specialist

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Manager & Professional
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210EJ Requisition #
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Independently investigate and respond to written/verbal appeals submitted by members, employees, contracted and non-contracted providers, Department of Financial Services (DFS), Attorney General (AG), Department of Health (DOH), Executive or Congressional branches with customized responses based on the issues presented by the appellant.  Complete responses in accordance with Emblem Health policies and procedures as well as the regulations by NCQA, CMS, NY State and other entities. The types of correspondence handled by the individual will include, but are not limited to, prompt-pay inquiries, complaints, administrative and utilization review appeals, second level complaints, second level administrative appeals, Medicare standard, and Expedited appeals for all lines of business. Review complex cases, analyze and summarize for senior management and regulatory entities. Responsible for mentoring specialists and providing assistance to them on complex cases. A critical function of this position is the ability to work independently.

Responsibilities

  • Independently 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. 
  • Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities.  Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc. as applicable.
  • Make critical decisions regarding research and investigation to appropriately resolve all inquiries.  Prepares cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.  Make recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit and contract materials.  Present findings and recommendations to appropriate parties for sign-off.
  • 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.
  • Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
  • Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant’s issues and are structurally accurate.  Responsible for ensuring responses are completed within the applicable regulatory timeframe.
  • Review payments issued by the organization to ensure that they are in compliance with Prompt Pay and CMS Regulations.  Prepare Prompt Pay grids as needed.  Determine if interest is due based on findings and calculate interest amount.
  • Complete submission of case files and responses to entities such as DFS, DOH, AG and Maximus; ensure timely and appropriate response submissions.
  • Document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
  • Identify workflow improvements and work with the team to enact change.
  • Provide recommendations to management regarding issue resolution, root cause analysis and best practices.
  • Serves as a point of escalation for problems, providing guidance and expertise to team members as well as helping to identify and address core business requirements
  • On board, train and serve as mentor for new G&A Specialists.
  • Serves as a coach and mentor to the associates providing support and guidance in complex situations.
  • Independently research, resolve and respond to escalated, complex cases, including but not limited to, executive complaints, legal, and social media.
  • Performs other duties as assigned or required.

Qualifications

  • Associates degree required, in a related field. Bachelor's degree preferred
  • Minimum 2 years’ experience as a G & A Specialist or 5 years of related experience in Grievance & Appeals
  • Must meet and maintain acceptable attendance standards with minimal unscheduled PTO
  • Must exceed median production and compliance standards for both case resolution and data requirements
  • Extensive knowledge and experience in claims, enrollment, benefits and member contracts required
  • Ability to mentor specialists and provide assistance on complex cases required
  • Must be well versed in all aspects of the complaint, grievance and appeal process and be able to process all types of correspondence handled by Grievance and Appeals required
  • Proficiency in MS Office applications (especially word processing, and database/spreadsheet) required
  • Excellent product knowledge 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
  • Demonstrate leadership skills preferred
  • Takes initiative to guide and mentor others preferred

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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