Remote Clinical Appeals & Grievances Specialist

HealthFirst; Bismarck (ND); A distancia; USD 83.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical insurance

Dental insurance

Vision coverage

401k contributions

Life insurance

Descripción de la vacante

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution while ensuring compliance with applicable laws. The role may be remote or on-site at NYC or Lake Mary, FL, with travel as needed.

The position requires a Bachelor's degree and experience in appeals, grievances or utilization management, plus proficiency with Word, Excel, and HF Management Services systems.

Formación

• Bachelor's degree required; clinical background preferred.
• Experience in appeals and grievances, claims processing, utilization review or case management.
• Understanding of Utilization Review Guidelines (NYS ART 44/49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
• Ability to work independently across Word, Excel, email and filing systems.

Responsabilidades

• Develop and resolve clinical cases with supporting documentation.
• Meet regulatory timeframes for case processing.
• Maintain productivity and quality metrics for the Specialist role.
• Prepare cases for Medical Director Review with all pertinent information.

Conocimientos

Clinical case development

Regulatory compliance

Claims processing

Utilization review/guidelines

Computer proficiency (Word, Excel, e‑m

Educación

Bachelor's degree

Herramientas

Microsoft Word

Microsoft Excel

HF Management Services system

Descripción del empleo

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution while ensuring compliance with applicable laws. The role may be remote or on-site at NYC or Lake Mary, FL, with travel as needed.

The position requires a Bachelor's degree and experience in appeals, grievances or utilization management, plus proficiency with Word, Excel, and HF Management Services systems.