Clinical Appeals & Grievances Expert (RN)

Healthfirst; New York (NY); Hybrid; USD 83,100 - 120,360; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Job summary

Healthfirst is seeking an A&G Clinical Specialist to lead the development and resolution of clinical cases for member and provider appeals, ensuring compliance with applicable laws and internal policies.

The role can be remote or on-site at the NYC or Lake Mary locations, with travel as needed. You will manage your own caseload, perform issue research, interpret guidelines, and prepare cases for internal and external reviews.

Qualifications

• RN required for eligibility to apply.
• Bachelor’s degree preferred.
• Experience in appeals & grievances, claims processing, utilization review or case management is advantageous.
• Ability to work independently across multiple computer applications and systems.

Responsibilities

• Research issues and develop clinical case resolutions with thorough documentation.
• Interpret regulations and internal policies to frame decisions.
• Prepare cases for Medical Director Review and external appeal processes.
• Manage caseload within regulatory timeframes and ensure timely handoffs.

Skills

RN

Education

Bachelor’s degree

Tools

Microsoft Word

Excel

Macess

Microsoft Outlook

Job description

Healthfirst is seeking an A&G Clinical Specialist to lead the development and resolution of clinical cases for member and provider appeals, ensuring compliance with applicable laws and internal policies.

The role can be remote or on-site at the NYC or Lake Mary locations, with travel as needed. You will manage your own caseload, perform issue research, interpret guidelines, and prepare cases for internal and external reviews.