Clinical Appeals & Grievances Specialist (Remote)

HealthFirst; South Dakota Park (SD); A distancia; USD 83.000 - 120.000; Jornada completa

Descripción de la vacante

HealthFirst is seeking an Appeals & Grievances (A&G) Clinical Specialist to lead clinical case development and ensure regulatory compliance. The role handles DOH and executive complaints and may manage clinical claim appeals from participating and non-participating providers.

Location includes remote or on-site options at NY or FL offices; travel to meetings may be required. Strong knowledge of utilization review guidelines and case management is expected.

Formación

• RN
• LPN
• Dental Hygienist
• Bachelor’s degree
• Experience in clinical practice with appeals & grievances, claims processing, utilization review or utilization management/case management
• Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
• Ability to work independently on Word, Excel, email and virtual filing systems

Responsabilidades

• Subject matter expert for clinical case development and resolution while ensuring compliance with Federal/State regulations
• Manage DOH and executive complaints as needed
• Handle clinical claim appeals from Healthfirst providers
• Develop cases for Medical Director Review with all supporting information
• Meet regulatory timeframes and maintain productivity/quality benchmarks

Descripción del empleo

HealthFirst is seeking an Appeals & Grievances (A&G) Clinical Specialist to lead clinical case development and ensure regulatory compliance. The role handles DOH and executive complaints and may manage clinical claim appeals from participating and non-participating providers.

Location includes remote or on-site options at NY or FL offices; travel to meetings may be required. Strong knowledge of utilization review guidelines and case management is expected.