Job Overview
Location
Remote
Job Type
Full-time
Category
Customer Success
Date Posted
May 17, 2026
Full Job Description
đź“‹ Description
- • Serve as the subject matter expert for non-clinical appeals and grievances cases across all Healthfirst lines of business, including commercial, Medicaid, dual enrollment, Medicare, and Complete Care.
- • Independently manage end-to-end development and resolution of member and non-contracted provider appeals, including claim denials, member complaints, and provider disputes.
- • Conduct thorough research to identify case-specific issues, referencing internal Healthfirst health plan policies, procedures, and external federal and state regulations to ensure compliance.
- • Interpret complex regulatory requirements and apply them accurately to case decisions, maintaining strict adherence to regulatory timeframes for resolution and response.
- • Draft, edit, and finalize all resolution letters with precision, ensuring clarity, accuracy, and compliance with payer guidelines and legal standards.
- • Prepare and submit well-documented appeals within timely filing limits, ensuring all necessary documentation and coding criteria are properly included.
- • Track and manage individual caseloads with accountability for both productivity and quality metrics as defined by established performance expectations.
- • Communicate proactively with colleagues to hand off or retrieve active cases, ensuring seamless workflow continuity and timely resolution.
- • Identify recurring patterns or trends in claim denials and appeals outcomes, providing actionable feedback to leadership for process improvement initiatives.
- • Maintain up-to-date knowledge of payer policies, industry regulations, coding updates, and compliance requirements to maximize reimbursement and minimize errors.
- • Work autonomously with sound judgment to initiate case development with internal and external stakeholders, following prescribed Job Aid timelines and regulatory deadlines.
- • Ensure all case documentation is complete, accurate, and audit-ready to support compliance reviews and regulatory audits.
- • Perform additional duties as assigned to support the Appeals & Grievances unit’s mission and operational goals.
🎯 Requirements
- • HS Diploma or GED from an accredited institution
- • Minimum of two (2) years of work experience in Managed Care Health Insurance Plan
- • Experience with appeals for Medicare, Medicaid, Dual enrollment, and commercial plans end to end
- • Claims processing experience with coding criteria is preferred
- • Demonstrated ability to work under pressure and manage tight timeframes
- • Demonstrated critical thinking and decision-making competencies
🏖️ Benefits
- • Medical, dental, and vision coverage
- • Life insurance
- • 401k contributions
- • Incentive and recognition programs
Skills & Technologies
About Healthfirst, Inc.
Healthfirst is a New York-based health insurance provider offering affordable, comprehensive plans to individuals, families, and seniors. For over 30 years, the company has delivered diverse options, including Essential Plans, Medicaid Managed Care, Child Health Plus, Marketplace plans, and specialized Medicare Advantage and Long-Term Care solutions. Healthfirst offers benefits like medical, prescription drug, dental, and vision coverage. Notably, Healthfirst maintains the only 5-star rated Essential Plan in New York for two consecutive years, solidifying its position as a trusted leader in accessible community healthcare.
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