Clinical Appeals Specialist – Grievances (Remote)

HealthFirst; Heber (UT); Remote; USD 83,000 - 120,000; Full time

Job summary

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to independently develop and resolve clinical cases, ensuring compliance with federal and state rules. You will manage a personal caseload, coordinate with Medical Directors, and prepare cases for external reviews or notices.

Position may be remote or on-site at NYC or Lake Mary, with travel as needed. Strong knowledge of utilization guidelines and experience in fast-paced environments are preferred.

Qualifications

• RN, LPN or Dental Hygienist.
• Bachelor’s degree preferred.
• Experience in appeals & grievances, claims processing, utilization review or utilization management/case management expected.

Responsibilities

• Manage clinical case development and resolution while ensuring regulatory compliance.
• Prepare cases for Medical Director Review and for external appeal processes.
• Investigate issues, reference policies, interpret regulations and document case progress.
• Handle DOH and executive complaints and coordinate with internal/external stakeholders.
• Ensure timely completion within regulatory timeframes and accurate hand-off to colleagues.

Skills

Clinical case management

Appeals & grievances

Regulatory knowledge

Independent work

Office & filing systems

Education

RN license

LPN license

Dental Hygienist license

Tools

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to independently develop and resolve clinical cases, ensuring compliance with federal and state rules. You will manage a personal caseload, coordinate with Medical Directors, and prepare cases for external reviews or notices.

Position may be remote or on-site at NYC or Lake Mary, with travel as needed. Strong knowledge of utilization guidelines and experience in fast-paced environments are preferred.