Appeals and Grievances Dismissal Specialist

The A&G Dismissal Specialist conducts outreaches to members/member representatives and non-contracted providers with compassionate high-quality care and support. The Dismissal Specialist is committed to ensuring members receive timely and fair resolutions while maintaining compliance with Federal and State regulations. He/she manages their own caseload and is accountable for adhering to processes as outlined in established policies, procedures, and job aids. The Dismissal Team handles all member representative-submitted grievances and standard appeals, as well as all post-service reconsiderations submitted by non-contracted providers.

Duties & Responsibilities

• Independently manage a caseload through the complete case lifecycle – first outreach through dismissal – and complete verbal outreach attempts
• Analyze incoming appeals and grievances to determine eligibility for dismissal based on Medicaid and Medicare guidelines, including timeliness, completeness, and procedural requirements
• Draft and issue outreach and dismissal letters that are clear, concise, member-friendly, and compliant with applicable regulatory standards and timeframes i.e., NYS DOH, CMS
• Meet or exceed established productivity and quality metrics
• Communicate with other departments//outside vendors (i.e., Care Management, Contact Center Operations, etc.) to confirm submitted information
• Learn, master, and adhere to the intricate, multi-step details of the Appointment of Representative (AOR) and Waiver of Liability (WOL) processes to ensure successful execution of daily tasks
• Maintain accurate and timely documentation in accordance with Healthfirst policies and audit-ready standards
• Consistently demonstrate reliability and adaptability by maintaining a strong presence in daily operations, promptly engaging in collaborative efforts with the team, and participating in team meetings//discussions
• Additional duties as assigned
  
  

Minimum Qualifications

• High School Diploma or GED from an accredited institution
• Work experience with appeals and grievances or healthcare environment
• Work experience requiring verbal and written communication that is clear, concise, grammatically correct, and professional
• Customer service experience including resolving escalated customer complaints or concerns
• Work experience requiring personal organization and attention to detail
• Experience handling complex situations and//or projects
• Microsoft Office Suite application work experience including Excel, Word, PowerPoint, and Outlook
  
  

Preferred Qualifications

• Experience with OnBase
• Bachelor’s Degree from an accredited institution
• Work experience communicating complex information and interacting with management
  
  

Compliance & Regulatory Responsibilities: See Above


License/Certification: N/A




Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070
• All Other Locations (within approved locations): $51,000 - $74,880
  
  

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.