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

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

Job summary

An innovative healthcare organization is seeking a dedicated Appeals and Grievances Clinical Specialist to manage member complaints and ensure compliance with regulations. This remote role involves investigating and resolving clinical cases, collaborating with various teams, and preparing cases for review. The ideal candidate will possess strong clinical knowledge, excellent communication skills, and the ability to manage a large caseload in a fast-paced environment. Join a forward-thinking company that offers comprehensive benefits and a supportive work culture, making a meaningful impact in the healthcare sector.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

401k Contributions

Qualifications

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

Responsibilities

• Develop and resolve clinical cases related to health plan policies.
• Document case notes and manage tasks within regulatory timeframes.

Skills

Clinical Case Development

Regulatory Compliance

Research Skills

Communication Skills

Decision Making

Education

RN, LPN, or Dental Hygienist

Bachelor’s Degree

Tools

Microsoft Word

Microsoft Excel

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 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 the subject matter expert responsible for clinical case development and resolution, ensuring adherence to Federal and/or State regulations. The incumbent manages their caseload, investigates, and resolves cases initiated by members or providers, including handling Department of Health (DOH) and executive 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, Reduction, Termination, and Suspension of services.
• Research issues, understand health plans policies, interpret regulations, and make decisions.
• Document case notes and summaries, manage tasks within regulatory timeframes, and communicate effectively with colleagues.
• Prepare cases for Medical Director review, external appeals, and ensure all pertinent information is included.
• 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 coverage guidelines.
• Proficiency with Microsoft Word, Excel, 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 NYC 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 relevant factors. Healthfirst offers comprehensive benefits including medical, dental, vision, life insurance, and 401k contributions.