Clinical Appeals & Grievances Specialist — Remote

HealthFirst; Wyoming (MI); Híbrido; USD 73.000 - 108.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical coverage

Dental coverage

Vision coverage

401k contributions

Descripción de la vacante

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution. You will handle complex cases, ensure compliance with federal/state regulations, and coordinate with Medical Directors and external appeal processes.

The role requires experience in appeals, grievances, and utilization review, with the ability to manage a large caseload in a fast-paced setting. Remote or on-site options are available, with travel as needed.

Formación

• RN, LPN or Dental Hygienist license required.
• Bachelor's degree preferred.
• Experience in appeals & grievances, claims processing, utilization review or case management is a plus.

Responsabilidades

• Develop and resolve clinical cases including pre-existing conditions, prior approval, medical necessity, pre-certification and continued stay.
• Research issues and reference HF policies to frame decisions.
• Prepare cases for Medical Director Review and external appeals through all levels of the process.
• Maintain timely file documentation and ensure regulatory timeframes are met.
• Communicate effectively to hand-off and coordinate with colleagues.

Conocimientos

RN/LPN/Dental Hygienist

Care management systems

TruCare/Hyland CCMS

Microsoft Word & Excel

Regulatory compliance

Educación

RN/LPN/Dental Hygienist license

Bachelor's degree

Herramientas

Microsoft Word

Excel

Macess

Descripción del empleo

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution. You will handle complex cases, ensure compliance with federal/state regulations, and coordinate with Medical Directors and external appeal processes.

The role requires experience in appeals, grievances, and utilization review, with the ability to manage a large caseload in a fast-paced setting. Remote or on-site options are available, with travel as needed.