Remote Clinical Appeals & Grievances Specialist

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

Benefits offered by this job

Medical, dental and vision coverage

Life insurance

401k contributions

Incentive programs

Job summary

Healthfirst is seeking an A&G Clinical Specialist to develop and resolve clinical cases, managing appeals, grievances and DOH complaints with strict regulatory compliance. The role supports medical necessity decisions, prior approvals and continued stay actions, working across vendors and internal teams.

The position is remote or on-site, with locations in New York City and Lake Mary, FL; travel may be required.

Qualifications

• RN, LPN, or Dental Hygienist background
• Bachelor's degree in a relevant field
• Experience in appeals & grievances, claims processing, utilization review or utilization management
• Familiarity with Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines

Responsibilities

• Develop and resolve clinical cases and ensure timely handling within regulatory timeframes
• Prepare cases for Medical Director Review with all pertinent information
• Manage DOH and executive complaints as needed
• Work independently across multiple computer applications (Word, Excel, email) and maintain compliance

Skills

Clinical case development

Regulatory compliance knowledge

Communication skills

Independent work

Education

Bachelor's degree

Tools

Microsoft Word

Excel

Job description

Healthfirst is seeking an A&G Clinical Specialist to develop and resolve clinical cases, managing appeals, grievances and DOH complaints with strict regulatory compliance. The role supports medical necessity decisions, prior approvals and continued stay actions, working across vendors and internal teams.

The position is remote or on-site, with locations in New York City and Lake Mary, FL; travel may be required.