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

Healthfirst; Connecticut; Remote; USD 81,000 - 117,000; Full time

Job summary

An established industry player is seeking a dedicated Appeals and Grievances Clinical Specialist to join their remote team. This role involves managing member complaints and appeals, ensuring compliance with federal and state regulations while providing exceptional service. You will be responsible for investigating cases, resolving issues, and preparing documentation for reviews. This position offers a competitive salary and comprehensive benefits, making it an excellent opportunity for professionals looking to make a significant impact in the healthcare field. If you are passionate about improving patient experiences and thrive in a fast-paced environment, this role is perfect for you.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401k Contributions

Qualifications

• RN, LPN, or Dental Hygienist required.
• Experience in clinical practice or case management preferred.

Responsibilities

• Manage clinical cases and ensure compliance with regulations.
• Document case notes and prepare cases for review.

Skills

Clinical Case Management

Regulatory Compliance

Effective Communication

Problem Solving

Education

Bachelor's Degree

Tools

Microsoft Word

Microsoft Excel

Virtual Filing Systems

Care Management Systems

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 presented by members or providers regarding the authorization or delivery of clinical and non-clinical services. A&G collaborates with internal and external divisions to resolve issues promptly and in compliance with regulations. The A&G Clinical Specialist is the subject matter expert responsible for clinical case development and resolution, ensuring adherence to Federal and State regulations. The role involves managing caseloads, investigating cases, and resolving member or provider-initiated issues, including handling Department of Health (DOH) and executive complaints, as well as clinical claim appeals from providers.

• This position is 100% remote. We are hiring for the following schedules:

• 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 such as pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services. The Specialist will:
• Research issues
• Ensure quality of care experience
• Reference and understand internal policies and procedures
• Interpret regulations
• Resolve cases and make critical decisions
• Document case notes and summaries
• Manage duties within regulatory timeframes
• Communicate effectively with colleagues
• Work within productivity and quality frameworks
• Prepare cases for Medical Director review and external appeals, ensuring all pertinent information is included
• Handle additional duties as assigned

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
• Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare guidelines
• Proficiency in Microsoft Word, Excel, email, and virtual filing systems (e.g., Macess). Experience with care management systems like CCMS, TruCare, Hyland
• Ability to manage large caseloads in a fast-paced environment

Hiring Range:

• Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480
• Other locations: $71,594 - $106,080

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

You will receive notifications for new jobs in CT. Enter your email below to be notified when new jobs are posted.

By creating an alert, you agree to our Terms. You can change your consent settings at any time as outlined in our Terms.

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Employers use Nursing Network daily to find candidates. Get listed so they can discover you.