Description and RequirementsThe Manager, Clinical Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Clinical 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.

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 assignedProvides oversight in case research and provides advice as neededUnderstands HF's internal health plans' policies and procedures to frame decisionsInterprets regulations to provide guidance to specialists on a daily basisEnsures the timely resolution of cases and makes critical decisionsFocuses on clinical criteria for expedited casesHelps standardize and optimize how Appeals and Grievances are routedDetermine best practices and strategically deploy approaches to meet production, compliance and quality targetsWorks with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gapsProvides guidance in the preparation of case preparation 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 caseHas oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal processAssists in leading the

AOR / WOL

Outreach team in coordination with the supervisorWorks with Providers and DSE on educating providers in how to submit Appeals timely and accurately.

Maintains delegated vendor relationship and ensure vendor performance and compliance measures are metInstitutes and manages working relationships within various operational areas to identify and execute overall process improvementsDiagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances teamIdentifies trends and recommends solutions for improvement.

Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functionsMaintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancementsAdditional duties as assigned

Minimum Qualifications:

Bachelor's degree from an accredited institution or equivalent work experienceRNExperience with utilization management or appeals and grievance processing and complianceWorking experience in a fast-paced environment overseeing multiple priorities, tasks and/or teamsProven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutionsExperience preparing and delivering written and verbal information to multiple types of audiencesDemonstrated ability to build and foster effective relationships

Preferred Qualifications:

Experience in clinical practice with a focus 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 guidelinesExtensive experience in healthcare appealsMBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administrationManagement experience in an operational department within the healthcare industry focused on clinical leadershipLeadership experience in a focus area of operational excellence or auditExperience developing strategy and processes for a department or functionExperience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team

Hiring Range:

Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430All Other Locations (within approved locations): $88,700 - $131,920As 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 \