Clinical Appeals & Grievances Specialist — Remote

Healthfirst; Texas; À distance; USD 73 000 - 120 000; Plein temps

Avantages offerts par ce poste

Medical, dental, vision coverage

401k contributions

Résumé du poste

Healthfirst is seeking an experienced Appeals & Grievances Clinical Specialist to manage a caseload of member and provider cases across NY and FL locations. You will ensure clinical case development, regulatory compliance, and timely resolution of complex appeals.

The role requires licensure as RN, LPN or Dental Hygienist, with preferred experience in utilization management or claims processing. Remote or on-site work options are available with periodic travel.

Qualifications

• RN, LPN or Dental Hygienist licensure required.
• Experience with appeals, grievances or claims processing a plus.
• Ability to navigate multiple computer applications and maintain documentation.
• Strong independent work habits and time management in a fast-paced environment.

Responsabilités

• Develop and resolve clinical cases with focus on medical necessity and pre-certification.
• Research issues and interpret applicable regulations and internal policies.
• Prepare cases for Medical Director Review and external appeal processes.
• Maintain timely file updates and communicate effectively with team members.

Connaissances

Clinical case management

Regulatory compliance

Medical terminology

Documentation & reporting

Formation

RN license

LPN license

Dental Hygienist license

Description du poste

Healthfirst is seeking an experienced Appeals & Grievances Clinical Specialist to manage a caseload of member and provider cases across NY and FL locations. You will ensure clinical case development, regulatory compliance, and timely resolution of complex appeals.

The role requires licensure as RN, LPN or Dental Hygienist, with preferred experience in utilization management or claims processing. Remote or on-site work options are available with periodic travel.