Clinical Appeals Specialist (Remote)

HealthFirst; Mississippi; Ibrido; USD 73.000 - 108.000; Tempo pieno

Descrizione del lavoro

HealthFirst seeks an A&G Clinical Specialist to drive clinical case development and resolution, ensuring regulatory compliance and timely handling of member and provider appeals. You will manage your own caseload, prepare materials for reviews, and coordinate with external processes as needed.

The role requires RN/LPN/Dental Hygist qualification with strong experience in utilization review, claims processing and care management systems, plus proficiency in Word, Excel and email.

Competenze

• RN, LPN or Dental Hygienist required.
• Experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
• Knowledge of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
• Proficiency with Word, Excel and corporate email; familiarity with care management systems (CCMS, TruCare, Hyland).

Mansioni

• Develop and resolve clinical cases end-to-end; research issues and interpret regulations; maintain timely file documentation.
• Prepare cases for Medical Director Review and for Maximus Federal Services, Fair Hearing and External Appeal.
• Handle additional duties as assigned.

Conoscenze

Ability to work independently across多个

Formazione

RN or LPN or Dental Hygienist

Bachelor’s degree

Strumenti

Microsoft Word

Excel

Macess

CCMS

TruCare

Hyland

InterQual

Milliman

Medicare local coverage guidelines

Descrizione del lavoro

HealthFirst seeks an A&G Clinical Specialist to drive clinical case development and resolution, ensuring regulatory compliance and timely handling of member and provider appeals. You will manage your own caseload, prepare materials for reviews, and coordinate with external processes as needed.

The role requires RN/LPN/Dental Hygist qualification with strong experience in utilization review, claims processing and care management systems, plus proficiency in Word, Excel and email.