Sr. Specialist, G & A

Summary of Position

Independently investigate and respond to written/verbal appeals submitted by members, employees, contracted and non-contracted providers, Department of Financial Services (DFS), Attorney General (AG), Department of Health (DOH), Executive or Congressional branches with customized responses based on the issues presented by the appellant. Complete responses in accordance with Emblem Health policies and procedures as well as the regulations by NCQA, CMS, NY State and other entities. The types of correspondence handled by the individual will include, but are not limited to, prompt-pay inquiries, complaints, administrative and utilization review appeals, second level complaints, second level administrative appeals, Medicare standard, and Expedited appeals for all lines of business. Review complex cases, analyze and summarize for senior management and regulatory entities. Responsible for mentoring specialists and providing assistance to them on complex cases. A critical function of this position is the ability to work independently.

Principal Accountabilities

• Independently review and evaluate appeal and grievance requests to 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 written acknowledgment of member and provider correspondence.
• Independently 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. Prepares 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 resolution of cases.
• Follow-up with responsible departments and delegated entities to ensure compliance.
• Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
• Independently prepare well written, customized responses to all correspondence that appropriately and completely address the complainant's issues and are structurally accurate. Responsible for ensuring responses are completed within the applicable regulatory timeframe.
• Review payments issued by the organization to ensure that they are in compliance with Prompt Pay and CMS Regulations. Prepare Prompt Pay grids as needed. Determine if interest is due based on findings and calculate interest amount.
• Complete submission of case files and responses to entities such as DFS, DOH, AG and Maximus; ensure timely and appropriate response submissions.
• Document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
• Identify workflow improvements and work with the team to enact change.
• Provide recommendations to management regarding issue resolution, root cause analysis and best practices.
• Serves as a point of escalation for problems, providing guidance and expertise to team members as well as helping to identify and address core business requirements.
• On board, train and serve as mentor for new G&A Specialists.
• Serves as a coach and mentor to the associates providing support and guidance in complex situations.
• Independently research, resolve and respond to escalated, complex cases, including but not limited to, executive complaints, legal, and social media.
• Performs other duties as assigned or required.