Appeals and Grievances Clinical Specialist

Healthfirst; New Jersey; Hybrid; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Paid time off

Job summary

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution within the Appeals & Grievances unit. You will handle cases from intake to final decision, ensuring compliance with federal and state regulations while coordinating with internal and external partners.

The role may be remote or on-site at NYC or Lake Mary locations, with occasional travel as needed. You will manage a caseload, prepare cases for review, and document findings to support timely,

Qualifications

• Must hold current RN, LPN, or Dental Hygienist license and be eligible to practice in applicable state documents.
• Bachelor’s degree preferred.
• Experience with appeals & grievances, claims processing, utilization review or case management.
• Strong ability to navigate care management systems and multiple software tools.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions, prior approval, medical necessity, and continued stay decisions.
• Research issues, interpret regulations, and reference internal policies to frame decisions.
• Prepare cases for Medical Director Review and external appeals; ensure complete documentation.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor's degree

Tools

Microsoft Word

Excel

Email client

Macess

CCMS

TruCare

Hyland

Job description

Position Summary: The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers. This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida. This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy).

Duties And Responsibilities

• Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end to end process requires the Specialist to independently:
  • Research issues
  • Reference and understand HF’s internal health plans policies and procedures to frame decisions
  • Interpret regulations
  • Resolve cases and make critical decisions
  • Update file documentation such as the file notes and case summary
  • Manage all duties within regulatory timeframes
  • Communicate effectively to hand-off and pick-up work from colleagues
  • Work within a framework that measures productivity and quality for each Specialist against expectations
  • Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case
  • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
  • Additional duties as assigned

Minimum Qualifications

• RN , LPN OR Dental Hygienist

Preferred Qualifications

• Bachelor’s degree
• Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
• Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and Hyland.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
• All Other Locations (within approved locations): $73,400 - $108,160

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.