Professional, Senior Appeals Specialist

Join Us in Shaping the Future of Health Care

At MVP Health Care, we're on a mission to create a healthier future for everyone. That means embracing innovation, championing equity, and continuously improving how we serve our communities. Our team is powered by people who are curious, humble, and committed to making a difference-every interaction, every day. We've been putting people first for over 40 years, offering high-quality health plans across New York and Vermont and partnering with forward-thinking organizations to deliver more personalized, equitable, and accessible care. As a not-for-profit, we invest in what matters most: our customers, our communities, and our team.

What's In It For You

• Growth opportunities to uplevel your career
• A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team
• Competitive compensation and comprehensive benefits focused on well-being
• An opportunity to shape the future of health care by joining a team recognized as a Best Place to Work For in the NY Capital District, one of the Best Companies to Work For in New York, and an Inclusive Workplace.

You'll contribute to our humble pursuit of excellence by bringing curiosity to spark innovation, humility to collaborate as a team, and a deep commitment to being the difference for our customers. Your role will reflect our shared goal of enhancing health care delivery and building healthier, more vibrant communities.

About The Opportunity

As a Sr. Appeals Specialist at Corporate, you will play a crucial role in the nuanced landscape of healthcare, insurance or other related fields, focusing on reviewing and processing Quality of care concerns and complaints, as well as complaints and appeals filed by regulatory agencies (i.e.: DOH, Attorney General, DFS). You will also work with our Legal department in reviewing and preparing appeals for Fair Hearing. You will be based at our HQ-Health Management location. The role demands a meticulous approach to understanding policies, regulations and specific circumstances surrounding each case. The Sr. Appeals Specialist ensures that every case is evaluated thoroughly and timely, applying appropriate guidelines and processes. In this position, you contribute to the overall satisfaction and trust of the regulators and stakeholders involved, while also maintaining standards and reputation of the organization they represent.

Qualifications You'll Bring

• Bachelor's degree in law, healthcare administration, business or related field required
• Associate's Degree with minimum 5 years' healthcare experience in lieu of Bachelor's Degree
• Strong attention to detail and ability to manage multiple tasks simultaneously.
• Excellent communication skills, both written and verbal.
• Exceptional customer service skills and ability to handle difficult situations with empathy and professionalism.
• Proficient in using computer systems and software, including Microsoft Office Suite.
• Ability to work independently and as part of a team in a fast-paced environment.
• Strong organizational and time management skills.
• Curiosity to foster innovation and pave the way for growth
• Humility to play as a team
• Commitment to being the difference for our customers in every interaction

Your Key Responsibilities

• Review and analyze regulatory complaints and appeals ensuring that the cases are thoroughly investigated.
• Ensure compliance with State and Federal regulations, including accreditation requirements (e.g.: CMS, Medicaid, NCQA).
• Timely response the regulatory agencies by the specified due date
• Collaborate with the Legal team in preparing case files for Fair Hearings
• Collaborate with internal and external stakeholders, as well as liaise with providers and enrollees as necessary to gather necessary documentation and information for case processing.
• Maintain accurate and up-to-date records of appeals, including documentation of all communication in the department's tracking system.
• Monitor track status of regulatory complaints and appeals throughout the case processing timeframes.
• Identify opportunities for process improvement and contribute to the development and implementation of best practices.
• Stay updated on changes in regulations and guidelines to ensure compliance and provide accurate information to enrollees.
• Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where You'll Be

Location: Remote

Pay Transparency

MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.

We do not request current or historical salary information from candidates.

$51,395.00-$68,354.75

MVP's Inclusion Statement

At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.

MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.

To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at [email protected] .