[Hiring] Grievance Specialist @HealthFirst

Role Description

The Grievance Specialist is a member of the Appeals & Grievances (A&G) team at Healthfirst and is responsible for managing and resolving member or authorized representative–initiated grievances and complaints across Healthfirst’s product lines. This is a non-clinical role focused exclusively on grievance and complaint resolution. The Specialist plays a key role in advocating for Healthfirst members by thoroughly investigating their concerns and ensuring timely, accurate, and compliant resolutions in accordance with regulatory requirements.

This position is 100% remote - Schedule M-F, 8am-4:30pm or 8:30am-5pm EST

• 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.

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.

Requirements

• Bachelor’s 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).

Benefits

• Medical, dental and vision coverage.
• Incentive and recognition programs.
• Life insurance.
• 401k contributions (all benefits are subject to eligibility requirements).