Clinical Appeals & Grievances Specialist - Remote/On-Site

HealthFirst; Oklahoma; Hybrid; USD 73,000 - 120,000; Full time

Job summary

HealthFirst is seeking an A&G Clinical Specialist to lead clinical case development and resolution within the Appeals & Grievances (A&G) unit. You will manage a caseload and ensure timely, compliant resolution of member and provider initiated cases, including DOH and executive complaints when needed.

The role may be remote or on-site at NYC or Lake Mary locations, with occasional travel to divisional meetings. Strong knowledge of regulations and health plan policies is essential.

Qualifications

• RN, LPN or Dental Hygienist licensure is required.
• Bachelor’s degree is preferred.
• Experience in appeals & grievances, claims processing, utilization review or utilization management/case management is preferred.
• Familiarity with Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines is expected.
• Proficiency with Microsoft Word, Excel, corporate email and filing systems; experience with care management systems is a plus.

Responsibilities

• Develop and resolve clinical cases, researching issues and interpreting regulations.
• Prepare cases for Medical Director Review and external appeal processes.
• Manage own caseload and ensure timely completion within regulatory timeframes.
• Communicate effectively to hand off work and document case notes.

Skills

Word processing

Excel

Email apps

Caseload management

Education

RN/LPN or Dental Hygienist license

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an A&G Clinical Specialist to lead clinical case development and resolution within the Appeals & Grievances (A&G) unit. You will manage a caseload and ensure timely, compliant resolution of member and provider initiated cases, including DOH and executive complaints when needed.

The role may be remote or on-site at NYC or Lake Mary locations, with occasional travel to divisional meetings. Strong knowledge of regulations and health plan policies is essential.