Senior G&A Specialist
 VNS Health | |
 United States, New York, New York | |
| 220 East 42nd Street (Show on map) | |
 Aug 12, 2026 | |
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Overview
Resolves grievances, appeals and external reviews for the multiple product lines of VNS Health ensuring that regulatory compliance, timeliness requirements and accuracy standards are met. Mentors Grievance & Appeals Specialists (GAS), Regulatory Specialists, and Senior Coordinators and assists with challenging cases. Performs second-level review on completed G&A cases where necessary to ensure quality and accuracy. Identifies and communicates areas for improvement in processes and training to G&A Management. Supports training and orientation of new staff. Coordinates efficient functioning of day-to-day operations, from intake to completion of cases, according to defined processes and procedures. Creates and maintains accurate records documenting the actions and rationale for each grievance or appeal decision. Supports management as needed in creation of intra-and inter-Departmental reporting of Grievance & Appeals data. Develops correspondence communicating the outcome of grievances and appeals to enrollees and providers and supports RN reviewers in doing same. Assists with collecting and reporting data. Identifies issues for escalation to Department management. Works under general supervision. Grievance & Appeals experience required. * Develops and maintains current knowledge of state/federal regulatory and contractual requirements related to all aspects of grievances and appeals for Medicare and Medicaid managed care organizations.* Mentors Grievance and Appeals Specialists, Senior Coordinators, Regulatory Specialists and supports skill development as needed while maintaining a case load of grievances and appeals. Assists with day to day operational issues, provides support with questions, and supports with coverage as needed which includes but is not limited to intake, grievances, appeals, regulatory complaints, and the level 2 appeal process for all lines of business. Identifies and assists with challenging cases, and classes of cases with greater potential impact on Department compliance, STARS, and other Plan priorities. Assists GASs in identifying issues for escalation to Department management.* Performs secondary review of GASs completed cases to ensure quality and accuracy. Recommends areas for GAS training and process improvements, trouble-shoots recurring problems that impact timely and complete resolution of grievances and appeals and escalates issues appropriately to Department management. Proposes solutions and improvements to address issues identified.* Investigates and reviews complex situations and underlying issues, analyzes and solves problems. Identifies issues for escalation to Department management. Consults with the members, families, providers and health plan departments as necessary. Appropriately identifies and communicates key points from details.* Investigates and coordinates the resolution of complex grievances and appeals according to defined processes and procedures ensuring that required timeframes and regulatory requirements are met, that accurate and timely follow up is completed and that activities are documented as required.* Reviews covered and coordinated services in accordance with established plan benefits, application of medical criteria and regulatory requirements to ensure appropriate appeal resolution and execution of the plan's fiduciary responsibilities. Prepares records for physician review as needed.* Conducts review of requests for prior authorization of health services, as required in certain product lines and prepares written response consistent with regulatory requirements.* Assist in monitoring the process for cases undergoing external review, when requested by enrollees, including preparation and submission of documentation according to regulatory requirements and tracking external reviews throughout the process until completion. External reviewers include New York State (Fair Hearings), Centers for Medicare and Medicaid Services, Independent Review Entities and Quality Improvement Organizations.* Collaborates with professionals, health plan departments such as Utilization and Care Management, Medical Directors, Compliance and Legal, as necessary, to investigate and facilitate resolution of individual grievances/appeals. Consults with enrollees, providers and the Medical Director. Supports G&A Management to identify root causes of clinical grievances and appeals and identify opportunities for improvement in other CHOICE departments.* Reviews information available from Medicaid and Medicare, other payers as appropriate and professional medical organizations regarding benefit levels and medical necessity criteria.* Enters data and assists with compiling reports and analysis on the grievance and appeals process. Supports management as needed in creation of intra-and inter-Departmental reporting of Grievance & Appeals data. * Participates in special projects and performs other duties as assigned. Qualifications Education: Bachelor's Degree in Health Care or equivalent required Work Experience: Minimum five years' professional experience in health care, including a minimum of two years in grievance and appeals conducting medical case review in a Managed Care setting requiredExcellent verbal/written communication skills and interpersonal skills requiredProficient computer and typing skills, and knowledge of Microsoft Office (Word and Excel) and database software requiredDemonstrated ability to work in a fast paced environment, to coach and mentor other staff members, and to effectively manage multiple grievances and appeals simultaneously required Pay Range USD $70,200.00 - USD $87,700.00 /Yr. About Us VNS Health has been committed to meeting the needs of New Yorkers for over 130 years. We're one of the largest nonprofit home- and community-based health care organizations in the country, and today, more than 11,500 team members work together to make a difference in the lives of more than 99,000 patients and members on any given day. | |