Manager, Appeals And Grievances

The Manager, Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee Internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels. This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

Work Schedule

This position requires three days per week in office (Tues/Wed/Thurs) at either: 100 Church St. New York, NY. or 1101 Greenwood Blvd. Lake Mary, FL.

Duties and Responsibilities:

• Ensure management team is accurately monitoring performance through daily meetings, coaching, feedback, documentation and disciplinary actions in collaboration with the Intake Vendor.
• Help Standardize and Optimize in how Appeals and Grievances are routed
• Work with Providers and DSE on educating providers in how to submit Appeals timely and accurately.
• Assist in leading the AOR / WOL Outreach team in coordination with the supervisor
• Identify trends and recommend solutions for improvement.
• Determine best practices and strategically deploy approaches to meet production, compliance and quality targets and to perform all Appeals & Grievances tasks
• Manage, develop and engage team. Work with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
• Maintain delegated vendor relationship and ensure vendor performance and compliance measures are met
• Institute and manage working relationships within various operational areas to identify and execute overall process improvements
• Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
• Diagnose and understand operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
• Focused on clinical criteria for expedited cases
• Drive the development of innovative tools and processes to assist in overall handling of Appeals & Grievances functions
• Working with the delegated vendor to identify opportunities to increase the rate in which SLA's are met
• Support use and updates of systems in place for delivery of quality of results
• Maintain knowledge of industry trends, best practices and protocols. Collaborate and share best practices with other units comprising the enterprise to ensure general consistencies and enhancements
• Additional duties as assigned

Minimum Qualifications:

• Bachelor's degree from an accredited institution or equivalent work experience
• Experience with appeals and grievance processing and compliance
• Experience building and managing a team and leading work processes in a fast-paced environment
• Experience preparing and delivering written and verbal information to multiple types of audiences
• Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions
• Experience setting direction for department and managing staff performance
• Experience managing multiple concurrent priorities.
• Proven ability to work across areas in an organization to yield results

Preferred Qualifications:

• Extensive experience in the healthcare appeals experience
• MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
• Leadership experience in an focus area of operational excellence or audit
• Management experience in an operational department within the healthcare industry focused on clinical leadership
• Experience developing strategy and processes for a department or function
• Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.

Know Your Rights

All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

• All Other Locations (within approved locations): $88,700 - $131,920

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.