Lead Clinical Appeals Specialist (Remote)

HealthFirst; Santa Fe (NM); Hybrid; USD 73,000 - 108,000; Full time

Job summary

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. The incumbent will manage a caseload and handle DOH and executive complaints, including clinical claim appeals when needed.

This is a remote or on-site position located at either 100 Church Street, New York City or 1101 Greenwood Avenue, Lake Mary, FL, with possible travel to divisional meetings.

Qualifications

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

Responsibilities

• Research issues and frame decisions based on internal policies and regulations.
• Interpret regulations and resolve cases with timely documentation and summaries.
• Prepare cases for Medical Director Review and external appeals.

Education

RN, LPN OR Dental Hygienist

Tools

Microsoft Word

Excel

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. The incumbent will manage a caseload and handle DOH and executive complaints, including clinical claim appeals when needed.

This is a remote or on-site position located at either 100 Church Street, New York City or 1101 Greenwood Avenue, Lake Mary, FL, with possible travel to divisional meetings.