Description and Requirements

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 has a hybrid work arrangement, partly office based either at 100 Church Street, NY, NY or Lake Mary, Florida and partly remote.

• 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.

• High School Diploma or GED
• 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.

• 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.