Clinical Appeals & Grievances Expert

HealthFirst; New Mexico; Hybrid; USD 73,000 - 120,000; Full time

Job summary

HealthFirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution, ensuring regulatory compliance. You will handle cases from initiation to disposition, collaborate with internal teams, and prepare submissions for external reviews while managing your own caseload.

You may work remotely or on-site at NY or Lake Mary, FL, with occasional travel to meetings. Strong knowledge of NY ART 44/49 PHL and care management systems is preferred.

Qualifications

• RN, LPN, or Dental Hygienist licensed.
• Experience in appeals & grievances, claims processing, utilization review or utilization management.
• Knowledge of Utilization Review Guidelines (NY ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines.

Responsibilities

• Develop and resolve clinical cases with documentation and regulatory timing.
• Prepare cases for Medical Director Review and external appeal processes.
• Manage caseload and coordinate with internal teams to ensure timely, compliant resolutions.

Skills

Clinical case management

Independent work in fast-paced env

Analytical research

Education

RN/LPN or Dental Hygienist license

Bachelor’s degree (preferred)

Tools

CCMS

TruCare

Hyland

Microsoft Word & Excel

Job description

HealthFirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution, ensuring regulatory compliance. You will handle cases from initiation to disposition, collaborate with internal teams, and prepare submissions for external reviews while managing your own caseload.

You may work remotely or on-site at NY or Lake Mary, FL, with occasional travel to meetings. Strong knowledge of NY ART 44/49 PHL and care management systems is preferred.