Clinical Appeals & Grievances Specialist (Remote)

HealthFirst; Montana; Remote; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401k contributions

Incentive programs

Job summary

HealthFirst seeks a Clinical Specialist for Appeals & Grievances to develop and resolve clinical cases in a compliant, timely manner. You will reference internal policies to frame decisions and manage complex cases from initial review through resolution.

The role supports remote or on-site work at NY/NJ/CT locations, with travel as needed. Strong clinical background and familiarity with UR guidelines are required.

Qualifications

• RN/LPN or Dental Hygienist licensure or credential required.
• Bachelor’s degree required.
• Experience in clinical practice with appeals/grievances, claims processing, utilization review or utilization management/case management.
• Understanding of Utilization Review Guidelines (e.g. NY ART 44 & 49 PHL), InterQual, Milliman or Medicare local coverage guidelines.

Responsibilities

• Develop and resolve clinical cases with comprehensive case documentation.
• Reference HF’s policies to frame decisions and ensure compliance with regulations.
• Manage duties within regulatory timeframes and measure productivity/quality.
• Prepare cases for Medical Director Review with complete case information.

Skills

Independent work

Office software

Regulatory knowledge

Education

RN/LPN/Dental Hygienist

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Job description

HealthFirst seeks a Clinical Specialist for Appeals & Grievances to develop and resolve clinical cases in a compliant, timely manner. You will reference internal policies to frame decisions and manage complex cases from initial review through resolution.

The role supports remote or on-site work at NY/NJ/CT locations, with travel as needed. Strong clinical background and familiarity with UR guidelines are required.