Clinical Appeals & Grievances Specialist (Remote)

HealthFirst; Manchester (NH); Hybrid; USD 83,000 - 120,000; Full time

Job summary

HealthFirst's Appeals & Grievances (A&G) unit handles member complaints, grievances and appeals related to authorization or delivery of services. The A&G Clinical Specialist is the subject matter expert responsible for clinical case development, resolution, and ensuring compliance with federal and state regulations.

The role may be remote or on-site at NY or Florida locations, with occasional travel to divisional meetings.

Qualifications

• Experience in clinical practice with appeals, grievances, claims processing, or utilization management.
• Understanding of Utilization Review Guidelines (e.g., NY ART 44/49, InterQual, Milliman, or Medicare LC guidelines).
• Ability to work independently using Word, Excel, and corporate email systems.

Responsibilities

• Develop and resolve clinical cases such as prior approvals and medical necessity.
• Prepare case documentation for Medical Director Review with all relevant data.
• Manage DOH and executive complaints as needed.
• Attend meetings and possibly travel to NY or Florida locations.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Email systems

Virtual filing system

Job description

HealthFirst's Appeals & Grievances (A&G) unit handles member complaints, grievances and appeals related to authorization or delivery of services. The A&G Clinical Specialist is the subject matter expert responsible for clinical case development, resolution, and ensuring compliance with federal and state regulations.

The role may be remote or on-site at NY or Florida locations, with occasional travel to divisional meetings.