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

Healthfirst; New York (NY); 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 ensuring compliance with healthcare regulations. You will be responsible for developing clinical cases, investigating issues, and preparing appeals. The ideal candidate will possess a nursing or dental hygiene license, with prior experience in clinical practice or case management being highly valued. This position offers a competitive salary and a comprehensive benefits package, making it an excellent opportunity for professionals looking to make a significant impact in healthcare.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

401k Plan

Qualifications

• Must have a valid RN, LPN, or Dental Hygienist license.
• Experience in clinical practice or case management preferred.

Responsibilities

• Manage and resolve clinical cases related to member complaints.
• Research and document case details while adhering to regulations.

Skills

Clinical Case Development

Regulatory Compliance

Research and Documentation

Utilization Review

Microsoft Office Proficiency

Education

RN, LPN, or Dental Hygienist License

Bachelor’s Degree

Tools

CCMS

TruCare

Hyland

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 authorization or delivery of services. The A&G Clinical Specialist is the subject matter expert responsible for clinical case development and resolution, ensuring compliance with regulations. The role involves managing caseloads, investigating, and resolving cases, including handling Department of Health complaints and clinical claim appeals.

Schedules Available:

• 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

Responsibilities:

• Develop and resolve clinical cases, including pre-existing conditions, prior approval, medical necessity, pre-certification, and service suspensions.
• Research issues, interpret regulations, document case details, and manage within regulatory timeframes.
• Prepare cases for review and appeals, ensuring all pertinent information is included.

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 (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare guidelines.
• Proficiency with Microsoft Office, email, virtual filing systems, and 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
• All Other Locations within approved areas: $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.