Expedited Appeals Specialist (Remote)

Company Statement

EmblemHealth is one of the nation’s largest not-for-profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

Expedited Appeals Specialist (Remote)

• Summary of Position: Responsible for processing expedited appeals: those that are complex in nature, require multiple hand-offs, and tend to have extremely tight deadlines. Ensure accuracy and compliance within the constraints of extremely quick turnaround times. Perform end-to-end G&A processing; consistently operate in a fast-paced high-pressure environment. Monitor all aspects of the G&A process; ensure that members have appropriate access to care.
• Principal Accountabilities:
• Independently perform triage function: review and evaluate appeal requests; identify and classify member and provider appeals. Using internal systems, determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
• Provide verbal and written member and provider correspondence as needed for authorized representative or needed clinical information.
• Conduct thorough investigations of all member and provider correspondence by analyzing all the issues presented and obtaining responses and information from internal and external entities. Validate the responses to ensure they address the issues and are supported by any contract stipulations, regulations, etc., as applicable.
• Make critical decisions regarding research and investigation to appropriately resolve all inquiries; prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the Plan’s determination; make recommendations on administrative decisions by preparing detailed case summaries and reviewing all applicable benefit and contract materials; present findings and recommendations to appropriate parties for sign-off.
• Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely authorization effectuation and resolution of cases.
• Perform necessary follow-up with responsible departments and delegated entities to ensure compliance.
• Maintain acceptable attendance standard with minimal unscheduled PTO.
• Exceed median production and compliance standards for both case resolution and data requirements.

Qualifications

• Bachelor’s degree
• 3 – 5+ years of related experience, preferably in the health industry and/or area of compliance
• Additional related experience/specialized training may be considered in lieu of degree requirements
• Extensive knowledge and experience in claims, enrollment, benefits, and member contracts
• Ability to mentor specialists and to provide assistance on complex cases
• Must be well versed in all aspects of the complaint, grievance and appeal process and be able to process all types of correspondence handled by Grievance and Appeals
• Proficiency in MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.)
• Excellent product knowledge
• Excellent prioritizing, organizing, time management, problem solving and analytical skills
• Ability to work under pressure and deliver complete, accurate, and timely results
• Leadership skills

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.