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

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

Job summary

An innovative healthcare organization is seeking a dedicated Appeals and Grievances Clinical Specialist. In this 100% remote role, you will manage member complaints and ensure compliance with regulations. Your expertise will be crucial in resolving clinical cases and collaborating across divisions. This position offers flexibility with various schedule options, allowing you to balance work and life effectively. Join a forward-thinking company that values your contributions and offers comprehensive benefits, including medical and 401k plans, to support your well-being.

Benefits

Comprehensive medical benefits

Dental and vision insurance

Life insurance

401k plan

Qualifications

• Experience in clinical practice or case management.
• Knowledge of Utilization Review Guidelines and Medicare guidelines.

Responsibilities

• Develop and resolve clinical cases related to member complaints.
• Document case notes and manage duties within regulatory timeframes.

Skills

Clinical case development

Regulatory compliance

Effective communication

Research and critical decision-making

Time management

Education

RN, LPN, or Dental Hygienist qualification

Bachelor’s degree

Tools

Microsoft Word

Microsoft Excel

Care management systems (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 across divisions to resolve issues promptly and compliantly. The A&G Clinical Specialist is a subject matter expert responsible for clinical case development and resolution, ensuring compliance with Federal and 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 internal policies, interpret regulations, and make critical decisions.
• Document case notes and summaries, manage duties within regulatory timeframes, and communicate effectively with colleagues.
• Prepare cases for Medical Director review, external appeals, and ensure all pertinent information is included.
• Handle additional duties as assigned.

Minimum Qualifications

• RN, LPN, or Dental Hygienist qualification.

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 computer applications such as Microsoft Word, Excel, email, and virtual filing systems. Experience with 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 certifications. Healthfirst offers comprehensive benefits including medical, dental, vision, life insurance, and 401k. The hiring range reflects the pay in good faith for new hires or transfers, subject to individual factors.