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Healthfirst Manager, A&G Performance Support in Lake Mary, Florida


The Manager of Appeals & Grievances Performance Support is responsible for managing several key functions in support of A&G; including regulatory reporting, analytics, root cause analysis, corrective action plan process, system/process implementations, and audit readiness.

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 provide production support through reporting and systems to ensure the highest compliance and quality are maintained.

Duties & Responsibilities:

  • Build and maintain repeatable and sustainable processes to ensure A&G inventory and production levels remain at the optimal level

  • Ensure business process performance standards are defined, measured & documented

  • Deliver productivity measurement and reporting needs for A&G teams

  • Recommend adjustments to business processes, systems, and staffing to optimize business performance

  • Ensure all phases of A&G processes remain compliant in aggregate and at the case level

  • Consider vendor operations in day to day activities to ensure compliance with Healthfirst and A&G standards

  • Recommend best practices and deploy approaches to performing Appeals & Grievances tasks

  • Support staff education of all A&G practices, processes and protocols and that change is communicated and implemented appropriately

  • Lead an audit support team to ensure A&G meets CMS & DOH regulatory requirements

  • Maintain working relationships within operations areas to identify and execute overall process improvements

  • Communicate A&G results and collaborate with operations areas to identify resulting process improvements

  • Build partnerships with business areas 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 A&G team

  • Support development of tools and processes to assist in overall handling of A&G functions

  • Lead and support operational and regulatory reporting needs

  • Lead and support new initiatives requiring A&G engagement

  • Additional duties as assigned

Minimum Qualifications:

  • Bachelor's degree from an accredited institution or equivalent work experience

  • Experience managing a team and leading work processes in a fast-paced environment

  • Experience preparing and delivering information to multiple types of audiences

  • Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions

  • Work experience with process improvement initiatives

  • Experience in supporting audits and regulatory requirements

  • Experience communicating and influencing impact and progress to senior leadership

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

  • Leadership experience in a focus area of audit, project management, or training design and delivery.

  • Management experience in an operational department within the healthcare industry

  • In-depth knowledge of the audit profession and auditing standards, policies and procedures

  • 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

  • Experience in A&G and federal/state requirement surrounding appeals and grievance processing

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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