A&G Clinical Coordinator - 100% Remote

The Appeals and Grievances Clinical Coordinator is responsible for supporting the clinical team to ensure timely and accurate processing of cases. The clinical coordinator properly sets up case files for clinical review as needed and conducts general appeal research and filing including but not limited to organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of the case, documentation of the appeal resolution and sending complete case files to external review organization as required by regulatory guidelines. The appeals and grievances may be related to all lines of business (Medicaid, Medicare, Commercial, etc.).

• Notifies team lead of identified patterns of appeals, claim errors, configuration issues or other systemic problems identified during appeal processing.
• Prepare evidence packages, makes calls and draft letters as needed.
• Acts/Serves as a liaison between the Health Plan and Member, Members Family and Providers during appeal processing and outcome
• Perform administrative activities including but not limited to generating and printing determination and authorization notification letters.
• Serves as a liaison in corresponding and communicating with providers and members as needed during appeal processing.
• Prepare cases for the clinical team by gathering documentation, loading evidence, and making calls to members and providers.
• Complete all associated data entry and authorization creation in the True care system.
• Ensures appeals and grievances are categorized and processed within New York state and federal timeframes.
• Additional duties as assigned.
• Correctly and completely preps completed case files for clinical review.
• Participate in meetings.
• Request denial files from delegated vendors and prepares cases for Clinical Specialist reviews.
• Maintains file integrity with regards to content and confidentiality.
• Interacts with other departments including Contact Center Operations, Claims, DSE, and E&B to resolve member and provider appeals.

Minimum Qualifications

• HS Diploma or GED

Preferred Qualifications

• Ability to work both independently and as a team member
• Knowledge of related NY state and federal regulations highly desirable
• Knowledge of claims payment process and claims data system (MHS)
• Bachelor’s degree
• Demonstrated ability to be deadline focused and to be flexible in order to adjust to priority changes
• Knowledge of the New York state ART 44 PHL and federal regulatory environment
• Proficiency in Microsoft Office required

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

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 [email protected] 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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

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): $46,200 - $62,400
• All Other Locations (within approved locations): $40,100 - $58,240

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.