Remote Clinical Appeals & Grievances Specialist

HealthFirst; Lincoln (NE); Remote; USD 73,000 - 108,000; Full time

Job summary

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. You will manage your own caseload and handle DOH and executive complaints as needed, with occasional travel to NYC or Lake Mary locations.

The role requires RN/LPN or Dental Hygienist background and a preference for a Bachelor's degree, with experience in utilization review or case management.

Qualifications

• RN, LPN, or Dental Hygienist license required.
• Preferred: Bachelor's degree and clinical appeals experience.
• Familiarity with Utilization Review guidelines and local coverage decisions.
• Strong research and case documentation skills.
• Ability to manage large caseloads in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases including Pre-existing Conditions, Prior Approval, and Medical Necessity.
• Research issues and interpret relevant regulations to frame decisions.
• Prepare cases for Medical Director Review and external appeals.
• Maintain accurate documentation and adhere to regulatory timeframes.
• Collaborate with internal teams and participate in meetings; travel as needed.

Skills

Independent work

Microsoft Word

Microsoft Excel

Communication skills

Education

Bachelor's degree

RN/LPN/Dental Hygienist license

Tools

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. You will manage your own caseload and handle DOH and executive complaints as needed, with occasional travel to NYC or Lake Mary locations.

The role requires RN/LPN or Dental Hygienist background and a preference for a Bachelor's degree, with experience in utilization review or case management.