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 Specialist
Summary of Job
Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with NCQA, CMS, State and other regulations. Process appeals and grievances to facilitate the accurate administration of benefits and clinical policy; ensure compliance of the appeal and grievance process with all regulatory requirements and NCQA standards. Work as an effective interface between internal and external customers. 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.
Qualifications:
- Associate Degree in a related field; Bachelor’s (Preferred)
- 3+ years of related professional work experience (Required)
- Prior health industry and/or compliance work experience (Preferred)
- Additional years of experience/training may be considered in lieu of educational requirements (Required)
- Excellent verbal and written communications skills (Required)
- Experience in a managed care/compliance environment (Preferred)
Ability to comprehend and produce grammatically accurate, 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)
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.