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Key Responsibilities:

+ Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters.

+ Conduct detailed research by collaborating cross-functionally with internal departments (e.g., Member Services, Provider Operations, Clinical, Enrollment, Pharmacy) to identify root causes and recommend appropriate resolutions.

+ Partner with external vendors (e.g., DentaQuest, EyeMed, Logisticare vendors) to ensure member issues involving subcontracted services and ancillary benefits are appropriately addressed and resolved.

+ Draft and issue acknowledgement and resolution letters that are clear, and compliant with regulatory standards and timelines (e.g., NYS DOH, CMS, Medicaid Managed Care Model Contract).

+ Ensure timely and accurate case documentation in accordance with Healthfirst policies, regulatory requirements, and audit standards.

+ Participate in department meetings, quality audits, training sessions, in-person quarterly town halls and performance reviews as needed.

+ Meet department metrics for production and quality.

Minimum Qualifications:

+ HS Diploma or GED from an accredited institution.

+ Understanding of utilization management processes and how service authorizations impact member access to care and claims payment

+ Proficient in Microsoft Office Suite, including Excel (sort, track and filter trends), Word, PowerPoint, Outlook and case tracking systems. **Preferred Qualifications:**

+ Bachelors degree or equivalent experience in healthcare, public health, or a related field preferred.

+ 2+ years of experience in managed care, member services, or healthcare grievances or complaints resolution.

+ Working knowledge of Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and//or Health Insurance Exchange (Marketplace//QHP) programs.

+ Familiarity with applicable state and federal regulatory requirements, such as CMS regulations, the NYS Department of Health (DOH) Medicaid Managed Care Model Contract, and the Department of Financial Services (DFS).

+ Experience with or knowledge of claims processing and provider billing workflows.

+ Exposure to or direct experience with long-term services and supports (LTSS), including Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS).

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, 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.