Grievance Specialist

Description and Requirements

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, including Medicare, Medicaid, Child Health Plus (CHPlus), Senior Health Partners (SHP), Commercial Qualified Health Plans (QHP), Essential Plans (EP), and CompleteCare. 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.

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.

• 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.

• 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).