Clinical Appeals Specialist (Remote/Hybrid)

HealthFirst; Provo (UT); Hybrid; USD 73,000 - 108,000; Full time

Job summary

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to manage the development and resolution of clinical cases for members and providers, ensuring compliance with applicable federal and state regulations. The role handles end-to-end appeals and may involve travel between locations as needed.

You will assist in coordinating with Medical Directors, prep cases for external appeals, and manage a caseload within a fast-paced environment on remote or on-site assignments at designated

Qualifications

• Clinical practice experience with appeals and grievances, claims processing, utilization review or case management.
• Ability to work independently across multiple computer applications and filing systems.
• Strong understanding of regulatory guidelines and healthcare policies.

Responsibilities

• Develop and resolve clinical cases including Pre-existing Conditions, Prior Approval and Medical Necessity.
• Reference policies, regulations and guidelines to frame decisions and communicate outcomes.
• Prepare cases for Medical Director Review and for external appeals across all levels of the process.
• Maintain timely documentation and ensure regulatory timeframes are met.

Skills

Clinical experience

Attention to detail

Independent work

Microsoft Word/Excel

Education

Bachelor's degree

RN/LPN/Dental Hyg licensure

Tools

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to manage the development and resolution of clinical cases for members and providers, ensuring compliance with applicable federal and state regulations. The role handles end-to-end appeals and may involve travel between locations as needed.

You will assist in coordinating with Medical Directors, prep cases for external appeals, and manage a caseload within a fast-paced environment on remote or on-site assignments at designated