Clinical Appeals Specialist - Remote Case Resolution

HealthFirst; Maine; Hybrid; USD 73,000 - 108,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Life insurance

Job summary

Healthfirst seeks an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with federal/state rules. You will independently investigate, resolve, and document cases, handling DOH and executive complaints as needed and may attend meetings or travel.

The role supports complex pre-certification, medical necessity reviews, and external appeals, with collaboration across internal and external teams. Remote or on-site options available.

Qualifications

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

Responsibilities

• Develop and resolve clinical cases with research and decision making.
• Prepare cases for Medical Director Review and external appeals.
• Manage caseload within regulatory timeframes and document thoroughly.
• Handle duties related to DOH and executive complaints as needed.

Skills

RN

LPN

Dental Hygienist

Education

RN/LPN/Dental Hygienist license

Bachelor’s degree

Tools

Microsoft Word

Excel

Email systems

CCMS

TruCare

Hyland

Job description

Healthfirst seeks an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with federal/state rules. You will independently investigate, resolve, and document cases, handling DOH and executive complaints as needed and may attend meetings or travel.

The role supports complex pre-certification, medical necessity reviews, and external appeals, with collaboration across internal and external teams. Remote or on-site options available.