Grievance Specialist

Job description

The Grievance Specialist is a member of the Appeals & Grievances (A&G) team at Healthfirst and is responsible for managing and resolving member or authorized representative–initiated grievances and complaints across Healthfirst’s product lines, including Medicare, Medicaid, Child Health Plus (CHPlus), Senior Health Partners (SHP), Commercial Qualified Health Plans (QHP), Essential Plans (EP), and CompleteCare. This is a non-clinical role focused exclusively on grievance and complaint resolution. The Specialist plays a key role in advocating for Healthfirst members by thoroughly investigating their concerns and ensuring timely, accurate, and compliant resolutions in accordance with regulatory requirements. Key Responsibilities: - Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters. - Conduct detailed research by collaborating cross-functionally with internal departments (e.g., Member Services, Provider Operations, Clinical, Enrollment, Pharmacy) to identify root causes and recommend appropriate resolutions. - Partner with external vendors (e.g., DentaQuest, Eye...