Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote

Healthfirst; Alaska; Remote; USD 71,000 - 107,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated Appeals and Grievances Clinical Specialist. This fully remote role involves managing member complaints and appeals, ensuring compliance with regulations while developing and resolving clinical cases. The ideal candidate will have a strong clinical background and the ability to navigate complex regulatory environments. With a focus on effective communication and case management, this position offers the opportunity to make a significant impact in the lives of members. Comprehensive benefits and a competitive salary range are included, making this an attractive opportunity for qualified candidates.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401k Contributions

Life Insurance

Qualifications

• Must have an RN, LPN, or Dental Hygienist license.
• Experience in clinical practice and appeals & grievances is preferred.

Responsibilities

• Develop and resolve clinical cases related to member complaints.
• Research issues and manage regulatory timeframes effectively.

Skills

Clinical Case Management

Regulatory Compliance

Communication Skills

Research and Analysis

Education

RN, LPN, or Dental Hygienist License

Bachelor’s Degree

Job description

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Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote

Position Summary: The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances, and appeals related to the authorization or delivery of clinical and non-clinical services. The A&G Clinical Specialist is responsible for all clinical case development and resolution, ensuring compliance with Federal and State regulations. The role involves managing caseloads, investigating cases, and handling complaints from the Department of Health and executives, as well as clinical claim appeals from providers.

Work Schedule:

• EST Schedule: Wednesday through Saturday, 10-hour shifts, 7am-5:30pm
• Monday-Friday: 8am-5pm or 8:30am-5:30pm
• Tuesday-Saturday: 8am-5pm or 8:30am-5:30pm
• Wednesday-Sunday: 8am-5pm or 8:30am-5:30pm

Duties and Responsibilities:

• Develop and resolve clinical cases, including pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services.
• Research issues, interpret regulations, make decisions, document cases, and manage regulatory timeframes.
• Communicate effectively with colleagues and prepare cases for review and appeals.

Minimum Qualifications:

• RN, LPN, or Dental Hygienist

Preferred Qualifications:

• Bachelor’s degree
• Experience in clinical practice, appeals & grievances, claims processing, utilization review, or case management
• Knowledge of Utilization Review Guidelines and care management systems
• Ability to manage large caseloads in a fast-paced environment

Hiring Range:

• Greater NYC Area (NY, NJ, CT): $81,099 - $116,480
• Other Locations: $71,594 - $106,080

Your salary will depend on experience, education, licenses, and certifications. Healthfirst offers comprehensive benefits including medical, dental, vision, life insurance, and 401k contributions.