Clinical Appeals & Grievances Specialist (Remote)

HealthFirst; Louisiana; Hybrid; USD 83,000 - 120,000; Full time

Job summary

HealthFirst's Appeals & Grievances (A&G) unit handles member and provider complaints, grievances, and appeals related to clinical and non-clinical services. The A&G Clinical Specialist serves as the subject-matter expert for case development and resolution, ensuring compliance with Federal and State regulations and managing DOH and executive inquiries.

This remote or on-site role at NYC or Lake Mary requires preparing cases for Medical Director Review, meeting regulatory timeframes, and

Qualifications

• RN, LPN or Dental Hygienist required.
• Bachelor’s degree required.
• Experience in appeals, grievances, claims processing or utilization management.
• Knowledge of Utilization Review Guidelines (NYS ART 44/49 PHL), InterQual, Milliman or Medicare guidelines.
• Proficient with Word, Excel and corporate email systems.

Responsibilities

• Develop and resolve clinical cases in the Appeals & Grievances unit.
• Manage DOH and executive complaints as needed.
• Prepare case packages for Medical Director Review.
• Attend divisional meetings or town halls; travel as required.
• Ensure decisions comply with HF policies and regulatory requirements.
• Meet regulatory timeframes and maintain productivity/quality metrics.

Skills

RN/LPN/Dental Hygienist

Clinical appeals

Utilization guidelines

MS Word & Excel

Education

Bachelor’s degree

Job description

HealthFirst's Appeals & Grievances (A&G) unit handles member and provider complaints, grievances, and appeals related to clinical and non-clinical services. The A&G Clinical Specialist serves as the subject-matter expert for case development and resolution, ensuring compliance with Federal and State regulations and managing DOH and executive inquiries.

This remote or on-site role at NYC or Lake Mary requires preparing cases for Medical Director Review, meeting regulatory timeframes, and