Clinical Appeals & Grievances Specialist - Remote

Healthfirst; Florida; Remote; USD 73,000 - 108,000; Full time

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution for member and provider appeals. You will handle a caseload, ensure timely investigations, and maintain regulatory compliance.

Location may be remote or on-site at Lake Mary, FL or NYC; some travel may be required. Responsibilities include researching issues, preparing materials for Medical Director Review and external appeals, and collaborating with interdisciplinary teams.

Qualifications

• RN, LPN or Dental Hygienist licensed to practice.
• Preferred Bachelor’s degree.
• Experience in appeals & grievances, utilization review or case management.
• Familiarity with Utilization Review guidelines and related tools.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions and prior approvals.
• Prepare cases for Medical Director Review and external appeal.
• Manage and document case progress within regulatory timeframes.
• Collaborate with other departments and travel as needed.

Education

RN/LPN/Dental Hygienist license

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Microsoft Word

Excel

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution for member and provider appeals. You will handle a caseload, ensure timely investigations, and maintain regulatory compliance.

Location may be remote or on-site at Lake Mary, FL or NYC; some travel may be required. Responsibilities include researching issues, preparing materials for Medical Director Review and external appeals, and collaborating with interdisciplinary teams.