Remote Appeals & Grievances Clinical Specialist

Healthfirst; Pennsylvania; Remote; USD 73,000 - 120,000; 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 role manages a personal caseload and handles DOH and executive complaints as needed, with remote or on-site work at multiple locations.

The incumbent will prepare cases for review and external appeal processes, collaborating with medical directors and care-management teams.

Qualifications

• RN or LPN or Dental Hygienist required.
• Bachelor’s degree preferred.
• Experience in appeals & grievances, claims processing, utilization review or case management preferred.
• Proficient with multiple computer applications (Word/Excel/email) and care-management systems (CCMS/TruCare/Hyland).
• Ability to manage large caseloads in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension decisions.
• Research issues, interpret regulations, reference internal policies, and document case files clearly.
• Prepare cases for Medical Director Review, Maximus Federal Services, Fair Hearing and external appeals as needed.
• Ensure timely compliance with regulatory timeframes and effective hand-offs between colleagues.
• Attend divisional meetings and town halls as required, with travel as needed.

Skills

Communication

Time management

Independent worker

Attention to detail

Education

RN

LPN

Dental Hygienist

Bachelor’s degree

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

CCMS

TruCare

Hyland

MACess

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 role manages a personal caseload and handles DOH and executive complaints as needed, with remote or on-site work at multiple locations.

The incumbent will prepare cases for review and external appeal processes, collaborating with medical directors and care-management teams.