Remote Appeals and Grievances Clinical Specialist

HealthFirst; Indianapolis (IN); Remote; USD 73,000 - 108,000; Full time

Benefits offered by this job

Medical, Dental, Vision coverage

401k contributions

Incentive and recognition programs

Life Insurance

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development, investigations and resolutions for member and provider appeals. The role may be remote or on-site at approved locations and may involve travel per policy.

Responsibilities include handling complex cases, coordinating with Medical Directors, and preparing materials for hearings, while ensuring adherence to federal and state regulations and internal policies.

Qualifications

• RN, LPN OR Dental Hygienist.
• Bachelor’s degree preferred; experience in appeals & grievances, claims processing, utilization review or management.
• Familiarity with Utilization Review Guidelines (NYS ART 44/49 PHL), InterQual, Milliman or Medicare local coverage guidelines.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination and suspension of services.
• Independently research issues, reference HF policies, interpret regulations and resolve cases within regulatory timeframes.
• Prepare cases for Medical Director Review and for external appeal processes; maintain accurate documentation and handoffs.

Skills

Independent work

Communication

Research

Time management

Education

RN

LPN

Dental Hygienist

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Microsoft Word

Excel

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development, investigations and resolutions for member and provider appeals. The role may be remote or on-site at approved locations and may involve travel per policy.

Responsibilities include handling complex cases, coordinating with Medical Directors, and preparing materials for hearings, while ensuring adherence to federal and state regulations and internal policies.