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

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

Job summary

Join a forward-thinking company as an Appeals and Grievances Clinical Specialist. In this 100% remote role, you'll play a critical part in managing member complaints and appeals, ensuring compliance with regulations while collaborating with various divisions to resolve issues. Your expertise in clinical case management will be vital as you handle complex cases and work within productivity frameworks. This role offers a competitive salary range based on your experience and education, along with comprehensive benefits including medical, dental, vision, and a robust 401k plan. If you're passionate about making a difference in healthcare, this is the opportunity for you!

Benefits

Comprehensive medical insurance

Dental insurance

Vision insurance

401k plan

Flexible work schedule

Qualifications

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

Responsibilities

• Develop and resolve clinical cases related to member complaints.
• Ensure compliance with Federal and State regulations.

Skills

Clinical Case Management

Regulatory Compliance

Effective Communication

Research Skills

Education

RN, LPN, or Dental Hygienist License

Bachelor’s Degree

Tools

Microsoft Office

CCMS

TruCare

Hyland

Job description

You will receive notifications for new jobs in TN.

Be the first to see new jobs near TN!
Enter your email address 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.

Upload Your Resume

Employers use Nursing Network daily to search for the perfect candidate. Get listed so they can discover you.

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 related to the authorization or delivery of clinical and non-clinical services. A&G collaborates with various 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 compliance with Federal and/or State regulations. The incumbent manages their caseload, investigating and resolving cases initiated by members or providers, including Department of Health (DOH) and executive complaints. They may also handle 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. The process involves:
• Researching issues
• Ensuring quality of care
• Understanding internal policies and procedures
• Interpreting regulations
• Making critical decisions
• Documenting case notes and summaries
• Managing regulatory timeframes
• Effective communication with colleagues
• Working within productivity and quality frameworks
• Preparing cases for Medical Director review with all pertinent information
• Handling appeals through all levels, including external agencies
• Performing 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
• Knowledge of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare coverage 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 NYC Area (NY, NJ, CT): $81,099 - $116,480
• Other locations within approved areas: $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. The stated ranges are estimates of the pay scale for new hires or internal transfers.