Team Leader, Appeals and Grievances

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.

The A&G Non-Clinical Team Leader is the subject matter expert responsible for overseeing the execution and performance of the Non-Clinical Support Coordinator team. The incumbent will help guide and ensure the team can successfully gathering facts, documents, forms in order to sending out requests for information or case acknowledgment letters. The Team Leader will enable A&G Clinical and non-Clinical Specialists to bring cases to resolution in a timely and compliant manner.

This is an on-site position.

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
  • 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

Minimum Qualifications:
  • Bachelor's degree from an accredited institution or relevant experience

Preferred Qualifications:
  • 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), InterQual, 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, 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 mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

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