Clinical Appeals Specialist – Grievances

Point32Health Services; United States; Sur place; USD 90 000 - 120 000; Plein temps

Avantages offerts par ce poste

Medical coverage

Dental coverage

Vision coverage

Retirement plan

Paid time off

Life and disability insurance

Tuition program

Well-being benefits

Résumé du poste

Point32Health is seeking a Clinical Consultant - Appeals & Grievances to support the department’s clinical operations and act as a liaison with internal teams and vendors. The role focuses on clinical guidance for appeals, collaboration with analysts, and independent work within a managed care environment covering Commercial and Medicaid programs.

Ideal candidates bring a strong clinical foundation, experience with grievances processes, and the ability to communicate complex medical concepts

Qualifications

• Clinical background in appeals/grievances and managed care.
• Ability to interpret medical terminology and plan of care.
• Experience interacting with analysts and cross-functional teams.

Responsabilités

• Serve as key clinical resource for Appeals & Grievances.
• Support analysts in medical terminology and provider plans.
• Analyze and advise on physician review needs.
• Identify complex cases and refer to case management as needed.
• Assess appeals drivers and assist leadership with messaging.
• Consult with MD reviewers on complex cases.
• Assist in case preparation and participate in committees.
• Contribute to new hire training on clinical aspects.
• Handle other duties as assigned.

Connaissances

Clinical knowledge

Communication skills

Independent work

Cross-functional collaboration

Description du poste

Point32Health is seeking a Clinical Consultant - Appeals & Grievances to support the department’s clinical operations and act as a liaison with internal teams and vendors. The role focuses on clinical guidance for appeals, collaboration with analysts, and independent work within a managed care environment covering Commercial and Medicaid programs.

Ideal candidates bring a strong clinical foundation, experience with grievances processes, and the ability to communicate complex medical concepts