Remote Clinical Appeals & Grievances Specialist

HealthFirst; Indiana; Remote; USD 83.000 - 120.000; Vollzeit

Benefits dieser Stelle

Medical, dental and vision coverage

Life insurance

401k contributions

Incentive programs

Zusammenfassung

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to develop and resolve clinical and non-clinical cases in a remote or on-site role at NYC or Lake Mary, FL. You will handle complex pre-certifications, medical necessity reviews, and continued stay decisions.

The role requires RN/LPN or dental hygienist background, a Bachelor’s degree, and experience with utilization review guidelines. Travel to meetings may be required.

Qualifikationen

• Experience in clinical practice with appeals & grievances, claims processing, utilization review or utilization management/case management.
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
• Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system.

Aufgaben

• Manage case development and resolution of clinical cases within regulatory timeframes.
• Prepare cases for Medical Director Review with all pertinent information.
• Attend divisional meetings and Town Halls as needed; travel may be required.

Kenntnisse

Clinical experience

Regulatory knowledge

Microsoft Word

Microsoft Excel

Email systems

Ausbildung

Bachelor’s degree

Tools

Word processing

Excel

Jobbeschreibung

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to develop and resolve clinical and non-clinical cases in a remote or on-site role at NYC or Lake Mary, FL. You will handle complex pre-certifications, medical necessity reviews, and continued stay decisions.

The role requires RN/LPN or dental hygienist background, a Bachelor’s degree, and experience with utilization review guidelines. Travel to meetings may be required.