Remote Appeals & Grievances Clinical Specialist

HealthFirst; South Dakota; Remote; USD 83,000 - 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 DOH and executive complaints and may handle clinical claim appeals from providers.

This position can be remote or on-site at NYC or Lake Mary, FL, with travel to meetings as needed. Candidates should possess a clinical license (RN/LPN/Dental Hygienist) and a Bachelor's degree, and be proficient with Word

Qualifications

• Nurse, LPN or dental hygienist backgrounds are considered.
• Experience in clinical appeals/grievances and claims processing is preferred.
• Knowledge of Utilization Review Guidelines and related guidelines is a plus.
• Strong proficiency with Word, Excel and corporate email systems.

Responsibilities

• Develop and resolve clinical cases and ensure compliance with applicable regulations.
• Manage DOH and executive complaints as needed.
• Prepare cases for Medical Director Review with all relevant information.
• Meet productivity and quality metrics and participate in divisional meetings as required.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor’s degree

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 DOH and executive complaints and may handle clinical claim appeals from providers.

This position can be remote or on-site at NYC or Lake Mary, FL, with travel to meetings as needed. Candidates should possess a clinical license (RN/LPN/Dental Hygienist) and a Bachelor's degree, and be proficient with Word