Remote Appeals & Grievances Clinical Specialist

Healthfirst

New Jersey

Hybrid

USD 83,000 - 120,000

Full time

4 hours ago

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Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Paid time off

Job summary

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution within the Appeals & Grievances unit. You will handle cases from intake to final decision, ensuring compliance with federal and state regulations while coordinating with internal and external partners.

The role may be remote or on-site at NYC or Lake Mary locations, with occasional travel as needed. You will manage a caseload, prepare cases for review, and document findings to support timely,

Qualifications

Must hold current RN, LPN, or Dental Hygienist license and be eligible to practice in applicable state documents.
Bachelor’s degree preferred.
Experience with appeals & grievances, claims processing, utilization review or case management.
Strong ability to navigate care management systems and multiple software tools.

Responsibilities

Develop and resolve clinical cases including pre-existing conditions, prior approval, medical necessity, and continued stay decisions.
Research issues, interpret regulations, and reference internal policies to frame decisions.
Prepare cases for Medical Director Review and external appeals; ensure complete documentation.

Skills

LPN

Dental Hygienist

Education

Bachelor's degree

Tools

Microsoft Word

Excel

Email client

Macess

CCMS

TruCare

Hyland

Job description

The role may be remote or on-site at NYC or Lake Mary locations, with occasional travel as needed. You will manage a caseload, prepare cases for review, and document findings to support timely,

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