CrawlJobs Logo

Manager, Appeals and Grievances

healthfirst.org Logo

Healthfirst

Location Icon

Location:
United States , New York ▼

Category Icon
Category:
Public Sector

Job Type Icon

Contract Type:
Not provided

Salary Icon

Salary:

103400.00 - 149430.00 USD / Year
Save Job
Save Icon
Apply Position

Job Description:

The Manager, Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee Internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels. This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

Job Responsibility:

  • Ensure management team is accurately monitoring performance through daily meetings, coaching, feedback, documentation and disciplinary actions in collaboration with the Intake Vendor
  • Help Standardize and Optimize in how Appeals and Grievances are routed
  • Work with Providers and DSE on educating providers in how to submit Appeals timely and accurately
  • Assist in leading the AOR / WOL Outreach team in coordination with the supervisor
  • Identify trends and recommend solutions for improvement
  • Determine best practices and strategically deploy approaches to meet production, compliance and quality targets and to perform all Appeals & Grievances tasks
  • Manage, develop and engage team. Work with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
  • Maintain delegated vendor relationship and ensure vendor performance and compliance measures are met
  • Institute and manage working relationships within various operational areas to identify and execute overall process improvements
  • Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands
  • Diagnose and understand operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
  • Focused on clinical criteria for expedited cases
  • Drive the development of innovative tools and processes to assist in overall handling of Appeals & Grievances functions
  • Working with the delegated vendor to identify opportunities to increase the rate in which SLA’s are met
  • Support use and updates of systems in place for delivery of quality of results
  • Maintain knowledge of industry trends, best practices and protocols. Collaborate and share best practices with other units comprising the enterprise to ensure general consistencies and enhancements
  • Additional duties as assigned

Requirements:

  • Bachelor's degree from an accredited institution or equivalent work experience
  • Experience with appeals and grievance processing and compliance
  • Experience building and managing a team and leading work processes in a fast-paced environment
  • Experience preparing and delivering written and verbal information to multiple types of audiences
  • Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions
  • Experience setting direction for department and managing staff performance
  • Experience managing multiple concurrent priorities
  • Proven ability to work across areas in an organization to yield results

Nice to have:

  • Extensive experience in the healthcare appeals experience
  • MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration
  • Leadership experience in an focus area of operational excellence or audit
  • Management experience in an operational department within the healthcare industry focused on clinical leadership
  • Experience developing strategy and processes for a department or function
  • Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team
What we offer:
  • medical, dental and vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions

Additional Information:

Job Posted:
March 13, 2026

Employment Type:
Fulltime
Work Type:
Hybrid work
Icon
Healthfirst - All Job Offers
Job Link Share:
Copy Link Icon
Facebook Icon Twitter Icon LinkedIn Icon

Looking for more opportunities? Search for other job offers that match your skills and interests.

Briefcase Icon

Similar Jobs for Manager, Appeals and Grievances

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...
Location
Location
United States , Phoenix
Salary
Salary:
Not provided
azblue.com Logo
Blue Cross Blue Shield of Arizona
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • 1 year experience in clinical and health insurance or other healthcare related field
  • 3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
  • 5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
  • 8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
  • Associate’s Degree in a healthcare field of study or Nursing Diploma
  • Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
  • Intermediate PC proficiency
  • Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
  • Maintain confidentiality and privacy
  • Advanced clinical knowledge
Job Responsibility
Job Responsibility
  • Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
  • Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
  • Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
  • Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
  • Maintain complete and accurate records per department policy.
  • Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
  • Demonstrate ability to apply plan policies and procedures effectively.
  • Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
  • Attend staff and interdepartmental meetings.
  • Participate in continuing education and current developments in the fields of medicine and managed care.
  • Fulltime
Read More
Arrow Right

A&G RN Coordinator

The RN Coordinator will investigate and respond to written and/or verbal clinica...
Location
Location
United States , New York
Salary
Salary:
110000.00 - 120000.00 USD / Year
mjhs.org Logo
MJHS
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Graduate of accredited nursing program
  • BSN preferred
  • 2 years managed care or hospital based utilization/case management experience
  • 2 years minimum clinical experience
  • Licensed nurse in New York State
  • Proficiency with Microsoft Word, Excel, Power Point and Outlook is required
  • Must have excellent written and verbal communication skills
  • Must be comfortable researching current evidence based practice guidelines and protocols
  • Must be able to multi-task and managed multiple projects efficiently, meet deadlines, demonstrate analytical/critical thinking skills, and provide excellent customer services that leads to positive problem resolution
Job Responsibility
Job Responsibility
  • Investigate and respond to written and/or verbal clinical appeals, expedited clinical grievances and potential quality of care grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS (Centers for Medicare & Medicaid Services), and DOH (Department of Health) regulations
  • Determines types of reconsiderations, redeterminations, action appeals, grievances, and grievance appeal
  • Investigation of Provider, Subscriber, Membership and Pharmacy Appeals to include: Reimbursement, Coding, Benefits, Pre-existing Conditions, Prior Approval, Medical Necessity, Precertification, Continued Stay, Reduction, Termination, and Suspension of services
  • Investigate and respond to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations
  • Documents all relevant information in the Appeals and Grievances determination process in the appropriate designated areas
  • Tracks departments’ compliance with requested action as a component of the Appeals and Grievances determination process
  • Presents cases to Appeals & Grievances File Review
  • Attend and represent A&G at NYS Fair Hearings/OTDA/ALJ Hearing as required
What we offer
What we offer
  • Sign-on Bonuses OR Student Loan Assistance for clinical staff
  • FREE Online RN to BSN and MSN degree programs
  • Tuition Reimbursement for all full and part-time staff
  • Dependent Tuition Reimbursement for clinical staff
  • Generous paid time off, including your birthday
  • Affordable and comprehensive medical, dental and vision coverage for employee and family members
  • Two retirement plans! 403(b) AND Employer Paid Pension
  • Flexible spending
  • Fulltime
Read More
Arrow Right

Lead Customer Solution Center Appeals and Grievances RN

The Lead Customer Solution Center Appeals and Grievances RN is responsible for a...
Location
Location
United States , Los Angeles
Salary
Salary:
102183.00 - 163492.00 USD / Year
lacare.org Logo
L.A. Care Health Plan
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Associate's Degree in Nursing for Registered Nurses
  • At least 8 years of clinical appeals and grievances experience in a managed care, utilization management and/or case management setting
  • At least 2 years in Medicare/ Medicaid in a managed care/ health plan environment
  • At least 1 year of leading a process, program, or staff experience
  • Extensive knowledge of healthcare regulations and managed care guidelines
  • Strong critical thinking and problem-solving abilities to assess complex clinical cases and evaluate medical necessity
  • Ability to communication, conflict resolution, and motivational skills
  • Ability to work independently and closely with a team in a collaborative and interactive environment
  • Ability to adjust to changing circumstances within the team
  • Good verbal and written communication skills
Job Responsibility
Job Responsibility
  • Assist with the development of a successful and cohesive Appeals and Grievance (A&G) clinical unit
  • Quality review of complex and/or escalated clinical A&G cases for all line of business (LOB)
  • Assist in identifying areas of improvement in increasing positive audit outcomes and improved Customer Service
  • Ensure the effective investigation and resolution of clinical grievances, appeals, complaints, and complex issues in alignment with L.A. Care policy and procedures and regulatory guidelines
  • Lead and work closely with assigned team daily
  • Mentor, coach, and may provide feedback to management on performance of staff
  • Review and process complex and/or escalated clinical A&G cases
  • Analyze patient medical records, clinical documentation, and insurance policies to determine medical necessity
  • Prepare and review A&G files for submission to providers and internal departments
  • Work with other departments to ensure all aspects of a case are appropriately managed
What we offer
What we offer
  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)
  • Fulltime
Read More
Arrow Right

HR Advisor

Join Our Client's Team as an HR Advisor! Are you a passionate HR professional lo...
Location
Location
United Kingdom , Worthing
Salary
Salary:
35000.00 - 43000.00 GBP / Year
https://www.office-angels.com Logo
Office Angels
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Training and coaching experience
  • Solid understanding of health and safety regulations
  • Familiarity in data reporting and analysis
  • Experience with performance development reviews
  • Thorough grasp of recruitment and onboarding processes
  • Proactive approach to addressing ad hoc HR queries
Job Responsibility
Job Responsibility
  • Employee Relations: Manage investigations, disciplinary actions, grievances, and appeals
  • Performance Management: Support managers on performance issues
  • Health & Well-being: Contribute to strategies promoting employee health and well-being
  • Recruitment & Onboarding: Collaborate on recruitment strategies
  • Data Management: Maintain and update the HR Information System
  • Policy Implementation: Review, update, and implement HR policies and procedures
What we offer
What we offer
  • Opportunity to make a tangible difference in employee engagement and well-being initiatives
  • Stay updated on changes in UK Employment Law and best practises
  • Undertake ad hoc projects and tasks requested by the Senior Leadership Team
  • Fulltime
Read More
Arrow Right

Senior Human Resources Manager

Aramark Healthcare+ is seeking candidates for a Senior Human Resources Manager p...
Location
Location
United States , Chicago
Salary
Salary:
Not provided
aramark.com Logo
Aramark
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Previous human resources experience crucial - preferably multi-site operation
  • Operational management experience preferable
  • Team building skills to plan, lead and empower all staff. Ability to collaborate closely with management.
  • Previous experience of a HRIS system
  • Good written and verbal communication skills, able to communicate and co-ordinate effectively at all levels in the organization. Is eloquent and a completer finisher.
  • Motivation - to work alone with no supervision - handling unstructured and diverse workload.
  • Action based and a natural Problem solver, results focused
  • Influencing skills and flexible and adaptable
  • Employee and consumer focus
  • Sound understanding of IT tools vital to own the documentation function
Job Responsibility
Job Responsibility
  • Act as company representative at management appeal interviews
  • Act as company representative at management grievance appeal interviews
  • Represent the company at all employment tribunals
  • Assist in company training programs
  • Ensure employee presentations are carried out where contract has been won.
  • Prepare reports as needed
  • Review employee relations queries that the HR Advisors are unsure of
  • Take care of any regional team management employee relations query that may lead to disciplinary action
  • Prepare material for employment tribunal claims.
  • Ensure that all managers in the region are kept up to date with any legal changes, with any HR company changes as coordinated by the company HR Director.
What we offer
What we offer
  • medical, dental, vision, and work/life resources
  • retirement savings plans like 401(k)
  • paid days off such as parental leave and disability coverage
  • Fulltime
Read More
Arrow Right

HR Generalist Manager

The HR Generalist Manager will provide vital support to the Senior Managers and ...
Location
Location
United States , Bentonville
Salary
Salary:
Not provided
aramark.co.uk Logo
Aramark UK
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Previous human resources experience crucial - preferably multi-site operation
  • Operational management experience preferable
  • Team building skills to plan, lead and empower all staff. Ability to collaborate closely with management.
  • Previous experience of a HRIS system
  • Good written and verbal communication skills, able to communicate and co-ordinate effectively at all levels in the organization. Is eloquent and a completer finisher.
  • Motivation - to work alone with no supervision - handling unstructured and diverse workload.
  • Action based and a natural Problem solver, results focused
  • Influencing skills and flexible and adaptable
  • Employee and consumer focus
  • Sound understanding of IT tools vital to own the documentation function
Job Responsibility
Job Responsibility
  • Act as company representative at management appeal interviews
  • Act as company representative at management grievance appeal interviews
  • Represent the company at all employment tribunals
  • Assist in company training programs
  • Ensure employee presentations are carried out where contract has been won.
  • Prepare reports as needed
  • Review employee relations queries that the HR Advisors are unsure of
  • Take care of any regional team management employee relations query that may lead to disciplinary action
  • Prepare material for employment tribunal claims.
  • Ensure that all managers in the region are kept up to date with any legal changes, with any HR company changes as coordinated by the company HR Director.
Read More
Arrow Right

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...
Location
Location
United States , New York City; Lake Mary
Salary
Salary:
73400.00 - 120360.00 USD / Year
healthfirst.org Logo
Healthfirst
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • RN, LPN
  • Bachelor’s degree
  • 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. Maces)
  • 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
Job Responsibility
Job Responsibility
  • Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
  • Research issues
  • Reference and understand HF’s internal health plans policies and procedures to frame decisions
  • Interpret regulations
  • Resolve cases and make critical decisions
  • Update file documentation such as the file notes and case summary
  • Manage all duties within regulatory timeframes
  • Communicate effectively to hand-off and pick-up work from colleagues
  • Work within a framework that measures productivity and quality for each Specialist against expectations
  • Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
What we offer
What we offer
  • medical, dental and vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions
  • Fulltime
Read More
Arrow Right

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...
Location
Location
United States , New York City; Lake Mary
Salary
Salary:
73400.00 - 120360.00 USD / Year
healthfirst.org Logo
Healthfirst
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • RN, LPN OR Dental Hygienist
  • Bachelor’s degree
  • 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
Job Responsibility
Job Responsibility
  • Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
  • Research issues
  • Reference and understand HF’s internal health plans policies and procedures to frame decisions
  • Interpret regulations
  • Resolve cases and make critical decisions
  • Update file documentation such as the file notes and case summary
  • Manage all duties within regulatory timeframes
  • Communicate effectively to hand-off and pick-up work from colleagues
  • Work within a framework that measures productivity and quality for each Specialist against expectations
  • Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
What we offer
What we offer
  • medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions
  • Fulltime
Read More
Arrow Right
Jobs by Category
Art and Entertainment Jobs Banking Jobs Call Center Jobs Construction Jobs Consulting Jobs Customer Service Jobs Education Jobs Energy Jobs Finance Jobs Gastronomy Jobs Health and Beauty Jobs Hospitality and Tourism Jobs Human Resources Jobs Insurance Jobs IT - Administration Jobs IT - Software Development Jobs Legal Jobs Logistics Jobs Manufacturing Jobs Marketing, Digital Marketing, SEO, SEM Jobs Media Jobs Nursing Jobs Office Administration Jobs Pharmacy Jobs Physical Work Jobs Public Relations Jobs Public Sector Jobs Purchasing Jobs Quality Control Jobs Real Estate Jobs Research and Development Jobs Sales Jobs
Job Positions Jobs by Country
United States Jobs United Kingdom Jobs India Jobs Canada Jobs Australia Jobs Germany Jobs Ireland Jobs Poland Jobs
Company
Blog About Us Contact
Follow Us
Facebook
X (Twitter)
LinkedIn
Instagram
CrawlJobs Group
ITFlashcards AllDevBlogs
© 2026 CrawlJobs Ltd. All Rights Reserved
Terms & Conditions Privacy Policy