Job Description

The Appeals & Grievances (A&G) team manages Healthfirst member complaints, grievances, and appeals. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. For those assigned to non-clinical appeals, this includes reviewing the initial claim denial for accuracy, requesting additional information that may influence the appeal’s outcome, and working to substantiate your decision based on applicable policies and/ or regulations. For those assisting with member complains requires our team members to exercise their critical thinking, retrace a member’s journey, coordinate with internal and external parties in the goal of making our member whole, and improving their circumstances.

The A&G Non-Clinical Team Leader is the subject matter expert responsible for overseeing the execution and performance of the non-clinical specialist. The incumbent will help guide their team, ensuring they can successfully gather facts, documents, apply sound decision making through the investigation, and send clear, accurate, grammatically correct member and provider facing letters, detailing the outcome of the investigation or appeal with the highest degree of quality within the timelines as required. Team leaders are also responsible for assisting in the selection of their team for any talent requisitions, performance management, and ensuring that cases are assigned to their team based on their team’s skill and training.

This position requires three days per week in office (Tues/Wed/Thurs) at 100 Church Street, NYC

Duties and Responsibilities:

• Manages a team of specialists, with responsibility for goal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned.

• Delivers training to employees as needed and ensures new hires are on-boarded and trained accordingly.

• Ensures Non-Clinical Staff expedite timely requests for information or case acknowledgement letters to meet compliance and productivity goals.

• Understands HF’s internal health plans policies and procedures to frame decisions.

• Interpret regulations and policies as needed.

• Makes critical decisions in support of the business as needed.

• Manage all duties within regulatory timeframes.

• Communicate effectively to hand-off and pick-up work from colleagues.

• Additional duties as assigned.

Minimum Qualifications:

• HS Diploma or GED from an Accredited Institution

• Excellent oral and written communication abilities.

• Proficiency in drafting clear and concise member and provider-facing letters that represent Healthfirst.

• Ability to work independently using computer applications like Microsoft Word, Excel, Teams, PowerPoint and SharePoint.

• Highly organized with the ability to manage multiple priorities effectively.

• Commitment to follow through on tasks and commitments.

Preferred Qualifications:

• Experience in coaching and mentoring staff to think critically and approach problem-solving strategically.

• Ability to foster a culture of continuous improvement.

• Demonstrated commitment to living Healthfirst values and culture drivers.

• Familiarity with our leadership compass.

• Prior work experience within a matrix organizational structure.

• Familiarity with various areas within Healthfirst, such as claims configuration, provider operations, payment integrity, call center, care management, enrollment, billing, and utilization management.

• Familiarity with A&G company policies and relevant regulations.

• Understanding of claim processing, including billing and coding.

• Knowledge of our authorization processes.

• Experience with corporate email and virtual filing systems (e.g., Macess).

• Familiarity with care management systems (e.g., TruCare, Hyland Onbase, SalesForce)

• Knowledge of epaccess/ MARx/ HHAexchange.

• Demonstrated ability to efficiently manage large caseloads for a team of specialists.

• Skill in triage, prioritization, and oversight to ensure high-quality case resolution within regulatory timeframes.

Compliance & Regulatory Responsibilities: N/A

License/Certification: N/A

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, LLCshallnotdiscriminateagainstanydisabledemployeeorapplicantinregard 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): $68,900 - $99,620

• All Other Locations (within approved locations): $61,300 - $89,440

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.