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Healthfirst Director of Appeals & Grievances Operations in Lake Mary, Florida


The Director of Appeals & Grievances Operations 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.

Duties & Responsibilities:

  • Develop staffing strategies and productivity standards to yield success

  • Ensure management team is accurately monitoring performance through daily meetings, coaching, feedback, documentation and disciplinary actions in collaboration with Human Resources.

  • 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

  • Communicate Appeals & Grievances results to senior leaders within the organization

  • 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

  • Drive the development of innovative tools and processes to assist in overall handling of Appeals & Grievances functions

  • 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

  • Support regulatory reporting and audit activities

  • Additional duties as assigned

Minimum Qualifications:

  • 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

Preferred Qualifications:

  • 5+ years of healthcare appeals experience

  • MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration

  • Six Sigma Black Belt or related process / operational improvement experience

  • Leadership experience in an focus area of operational excellence or audit

  • Management experience in an operational department within the healthcare industry

  • 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

Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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