Clinical Coordinator

Avature; New York (NY); Remote; USD 47,000 - 63,000; Full time

Job summary

An established industry player is seeking an Appeals and Grievances Clinical Coordinator to support their clinical team in ensuring timely and accurate processing of cases. This role involves gathering documentation, conducting appeal research, and coordinating with various departments to resolve appeals efficiently. The position is fully remote, offering flexible work schedules. Ideal candidates will have a high school diploma, knowledge of NY state regulations, and proficiency in Microsoft Office. This is a fantastic opportunity to contribute to a dynamic team while enjoying comprehensive benefits.

Benefits

Medical insurance

Dental insurance

Vision insurance

Life insurance

401k

Recognition programs

Qualifications

• High school diploma or GED is required.
• Knowledge of relevant state and federal regulations is highly desirable.

Responsibilities

• Support clinical team by processing appeals and grievances accurately.
• Gather documentation and prepare cases for review.
• Communicate with providers and members during the appeal process.

Skills

Knowledge of NY state and federal regulations

Proficiency in Microsoft Office

Understanding of claims payment processes

Ability to work independently

Ability to meet deadlines

Education

HS Diploma or GED

Job description

Appeals and Grievances Clinical Coordinator

The Appeals and Grievances Clinical Coordinator supports the clinical team to ensure the timely and accurate processing of cases. Responsibilities include setting up case files, conducting appeal research, requesting medical records, organizing documentation, preparing summaries, scheduling cases, processing reviews, documenting resolutions, and sending case files to external review organizations as required by regulatory guidelines. This role covers appeals related to all lines of business (Medicaid, Medicare, Commercial, etc.).

This position is 100% remote with options for a 4x10 or 5x8 work schedule.

1. Prepare cases by gathering documentation, loading evidence, and contacting members and providers.
2. Perform administrative tasks such as generating and printing determination and authorization letters.
3. Complete data entry and authorization creation in the True Care system.
4. Ensure case files are properly prepared for clinical review.
5. Notify the team lead of patterns in appeals, claim errors, or systemic issues.
6. Communicate with providers and members during appeal processing.
7. Coordinate with departments like Contact Center Operations, Claims, DSE, and E&B to resolve appeals.
8. Ensure appeals are processed within required timeframes.
9. Act as liaison between the health plan, members, families, and providers.
10. Prepare evidence packages, make calls, and draft letters as needed.
11. Request denial files from vendors and prepare cases for review.
12. Maintain file integrity and confidentiality.
13. Participate in meetings and perform additional duties as assigned.

Minimum Qualifications:

• HS Diploma or GED

Preferred Qualifications:

• Knowledge of NY state and federal regulations (highly desirable)
• Proficiency in Microsoft Office
• Knowledge of NY ART 44 PHL and federal regulatory environment
• Understanding of claims payment processes and data systems (e.g., MHS)
• Ability to work independently and in a team
• Ability to meet deadlines and adapt to changing priorities

Salary Range:

Greater NYC Area (NY, NJ, CT): $47,403 - $62,400

Other locations within approved areas: $41,101 - $60,320

Salary will depend on experience, education, licenses, and other relevant factors.

Healthfirst offers benefits including medical, dental, vision, life insurance, 401k, and recognition programs, subject to eligibility.

*The hiring range reflects the lowest and highest salaries Healthfirst would pay in good faith for this role.

Equal Opportunity Employment

Healthfirst is committed to diversity and equal employment opportunities. All applicants and employees are evaluated without regard to protected characteristics. Reasonable accommodations are available for applicants with disabilities. For accommodations, contact us at [e-mail] or 212-519-1798.