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

Healthfirst; New Jersey; Remote; USD 71,000 - 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 is pivotal in managing member complaints and appeals, ensuring compliance with regulations while providing exceptional service. You will be responsible for developing clinical cases and collaborating with various divisions to resolve issues efficiently. If you are passionate about making a difference in healthcare and have experience in clinical practice or case management, this opportunity offers a supportive environment with competitive benefits and a flexible schedule.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401(k) Plan

Qualifications

• Expertise in managing clinical cases and appeals.
• Understanding of Utilization Review Guidelines and regulations.

Responsibilities

• Develop and resolve clinical cases, ensuring quality of care.
• Communicate effectively and manage work within regulatory timeframes.

Skills

Clinical Case Development

Regulatory Compliance

Effective Communication

Critical Decision Making

Documentation

Education

RN, LPN, or Dental Hygienist License

Bachelor’s Degree

Tools

Microsoft Office

CCMS

TruCare

Hyland

Job description

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

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. The A&G Clinical Specialist is an expert responsible for clinical case development and resolution, ensuring adherence to Federal and/or State regulations. Responsibilities include managing caseloads, investigating cases, and handling Department of Health and external complaints, as well as clinical claim appeals from participating and non-participating 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, and service modifications. Tasks include:
• Research issues
• Ensure quality of care
• Understand internal policies and procedures
• Interpret regulations
• Make critical decisions
• Document case notes and summaries
• Manage work within regulatory timeframes
• Communicate effectively with colleagues
• Maintain productivity and quality standards
• Prepare cases for medical review and appeals, including external levels

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 with Microsoft Office, email, virtual filing, and care management systems like CCMS, TruCare, Hyland
• Ability to manage large caseloads in a fast-paced environment

Hiring Range:

• Greater NYC Area (NY, NJ, CT residents): $81,099 - $116,480
• Other locations within approved areas: $71,594 - $106,080

Salary and benefits depend on experience, education, licenses, and other factors. Benefits include medical, dental, vision, life insurance, and 401(k). The hiring range reflects good-faith estimates of starting salary.

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