申诉与投诉临床专员
Appeals and Grievances Clinical Specialist
职位概述：
申诉与投诉（A&G）部门负责处理Healthfirst会员或提供者提出的有关临床和非临床服务授权或提供的投诉、投诉和申诉。A&G与组织内外的部门协作，及时且合规地解决问题。
A&G临床专家是负责所有临床案件开发和解决的业务专家，同时确保符合联邦和/或州法规。该职位需管理自己的案件，并对调查和解决会员或提供者发起的案件负责。根据需要管理所有卫生部（DOH）和高管投诉。该职位也可能处理来自Healthfirst参与或非参与提供者的临床理赔申诉。
此职位为远程或现场办公，地点位于纽约市100 Church Street或佛罗里达州Lake Mary的1101 Greenwood Avenue。该职位可能需要参加A&G/运营部门的会议和全员大会，其中一些可能需要前往上述地点（差旅费用将按照政策报销）。
职责和任务：
· 负责临床案件的开发和解决，例如：既往症、事先批准、医疗必要性、预认证、持续住院、减少、终止和暂停服务。整个流程要求专家独立完成：
· 研究问题
- 参考并理解HF内部健康计划的政策和程序以做出决策
- 解释法规
- 解决案件并做出关键决策
- 更新文件记录，如文件备注和案件摘要
- 在监管时间范围内完成所有职责
- 有效沟通，以便与同事交接工作
- 在衡量每位专家生产力和质量的框架内工作
- 准备案件供医学总监审查，确保在调查过程中已获得所有相关信息（如案件摘要、合同信息、内部和外部回复、诊断以及CPT代码和描述），并在案件中呈现
- 通过申诉流程的所有层级准备案件提交给Maximus Federal Services、公平听证会和外部申诉
- 其他指派的任务
查看英文原文
Position Summary:
The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.
The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers.
This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy).Duties and Responsibilities:
· Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end to end process requires the Specialist to independently:
· Research issues
- Reference and understand HF’s internal health plans policies and procedures to frame decisions
- Interpret regulations
- Resolve cases and make critical decisions
- Update file documentation such as the file notes and case summary
- Manage all duties within regulatory timeframes
- Communicate effectively to hand-off and pick-up work from colleagues
- Work within a framework that measures productivity and quality for each Specialist against expectations
- Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
- Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
- Additional duties as assigned
Minimum Qualifications:
· RN, LPN, & Dental Hygienist
Preferred Qualifications:
- Bachelor’s degree
- Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
- Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
- Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and Hyland.
- Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
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 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): $83,100 - $120,360
- All Other Locations (within approved locations): $73,400 - $108,160
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.
Originally posted on Himalayas