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Clinical Team Lead, RN – Appeals and Grievances at Healthfirst

Clinical Team Leader, RN – Appeals and Grievances

  • Remote – NY
  • Telecommute, US
  • Full time
  • R009597

The A&G Clinical Team Leader, RN is the subject matter expert responsible for overseeing the execution and performance of the Clinical Specialist team all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will help the team manage caseload and is accountable for ensuring the team investigates and resolves member or provider initiated cases. The Team Leader provides guidance and input in helping the team manage 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 and may be responsible for stepping in to execute specific actions as needed to ensure timely completion of activities and to ensure compliance. Not limited to Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services.

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.

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 assigned
  • Provides oversight in case research and provides advice as needed
  • Understands HF’s internal health plans policies and procedures to frame decisions
  • Interpret regulations
  • Ensures the timely resolution of cases and makes critical decisions
  • Ensures file documentation is updated by team 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
  • Delivers training to employees as needed and ensures new hires are on-boarded and trained accordingly
  • Provides 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 case
  • Has oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
  • Additional duties as assigned

Minimum Qualifications:

  • RN

Preferred Qualifications:

  • Bachelor’s Degree from an accredited institution
  • Prior people management experience
  • 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), MCG, 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, OnBase, TruCare and Hyland.
  • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

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.

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