Remote Appeals & Grievances Clinical Specialist

HealthFirst; Central City (NE); Remote; USD 83,000 - 120,000; Full time

Job summary

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with applicable regulations. The role may be remote or on-site, with locations in New York City or Lake Mary, FL, and may require travel to divisional meetings.

The candidate will handle appeals, grievances and DOH cases, research issues, reference policies, prepare cases for review, and communicate findings with accuracy while meeting regulatory timeframes.

Qualifications

• RN, LPN or Dental Hygienist with relevant licensure.
• Experience in appeals, grievances, or claims processing preferred.
• Understanding of Utilization Review guidelines and related policies.

Responsibilities

• Develop and resolve clinical cases, including pre-approval, medical necessity, and continuation decisions.
• Prepare cases for Medical Director Review and for external appeals through all levels of the process.
• Manage own caseload, document findings, and meet regulatory timeframes.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor's degree

Job description

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with applicable regulations. The role may be remote or on-site, with locations in New York City or Lake Mary, FL, and may require travel to divisional meetings.

The candidate will handle appeals, grievances and DOH cases, research issues, reference policies, prepare cases for review, and communicate findings with accuracy while meeting regulatory timeframes.