Remote Appeals & Grievances Specialist (RN/LPN/DH)

Healthfirst; Pennsylvania; Remote; USD 71,594 - 106,080; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

401k

Flexible working hours

Job summary

A healthcare service provider is seeking an Appeals and Grievances Clinical Specialist to manage member complaints and clinical case resolutions. This is a 100% remote role requiring an RN, LPN, or Dental Hygienist license. Responsibilities include developing cases, researching issues, and ensuring compliance with regulations. Ideal candidates should have experience in clinical practice and knowledge of Utilization Review Guidelines. The position offers a competitive salary and an opportunity to work with a dynamic team.

Qualifications

• Must hold a valid RN, LPN, or Dental Hygienist license.
• Experience in clinical practice or case management is preferred.
• Must have an understanding of Utilization Review Guidelines.

Responsibilities

• Develop and resolve clinical cases related to patient services.
• Research and document issues, ensuring compliance with regulations.
• Communicate with colleagues and prepare cases for appeals.

Skills

Clinical case development

Effective communication

Regulatory compliance

Research and analysis

Education

RN, LPN, or Dental Hygienist License

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Care management systems (CCMS, TruCare, Hyland)

Job description

A healthcare service provider is seeking an Appeals and Grievances Clinical Specialist to manage member complaints and clinical case resolutions. This is a 100% remote role requiring an RN, LPN, or Dental Hygienist license. Responsibilities include developing cases, researching issues, and ensuring compliance with regulations. Ideal candidates should have experience in clinical practice and knowledge of Utilization Review Guidelines. The position offers a competitive salary and an opportunity to work with a dynamic team.