Remote Clinical Appeals & Grievances Specialist

HealthFirst; Bastrop (LA); Remote; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and ensure regulatory compliance for member complaints, grievances and appeals related to services and authorizations.

The role may be remote or on-site at NYCs 100 Church Street or Lake Mary, FL. Travel to divisional meetings and town halls could be required; relocation/telework policy applies.

Qualifications

• Bachelor’s degree required.
• Experience in clinical practice with appeals & grievances, claims processing, utilization review or utilization management/case management.
• Familiarity with Utilization Review Guidelines (e.g., NYS ART 44/49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
• Ability to work independently using Word, Excel, corporate email and filing systems.

Responsibilities

• Develop and resolve clinical cases including Pre-existing Conditions, Prior Approval, Medical Necessity and Continued Stay.
• Manage duties within regulatory timeframes.
• Work within a productivity/quality framework and meet set expectations.
• Prepare cases for Medical Director Review with complete case documentation.

Education

Bachelor’s degree

Tools

Microsoft Word

Excel

Email systems

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and ensure regulatory compliance for member complaints, grievances and appeals related to services and authorizations.

The role may be remote or on-site at NYCs 100 Church Street or Lake Mary, FL. Travel to divisional meetings and town halls could be required; relocation/telework policy applies.