Remote Clinical Appeals & Grievances Specialist

HealthFirst; Nebraska; Remote; USD 73,000 - 108,000; Full time

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution with strict adherence to federal and state regulations. You will handle DOH and executive complaints as needed while coordinating with internal and external stakeholders.

The role supports a flexible work arrangement (remote or on-site) at multiple locations and may involve travel for meetings.

Qualifications

• RN, LPN or Dental Hygienist licensure required or preferred.
• Bachelor’s degree is preferred; clinical experience in appeals/help desks favored.
• Experience in clinical practice with appeals, grievances, claims processing or utilization management.
• Familiarity with Utilization Review Guidelines and related tools is a plus.

Responsibilities

• Develop and resolve clinical cases, including pre-authorization, medical necessity, and continued stay.
• Prepare cases for Medical Director Review and for external appeals as needed.
• Manage own caseload and ensure timely regulatory-compliant investigations.
• Communicate case status and hand-off information to colleagues and leadership.

Education

RN

LPN

Dental Hygienist

Bachelor’s degree

Care management concepts

Appeals & grievances experience

Tools

Microsoft Word

Microsoft Excel

Email systems

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution with strict adherence to federal and state regulations. You will handle DOH and executive complaints as needed while coordinating with internal and external stakeholders.

The role supports a flexible work arrangement (remote or on-site) at multiple locations and may involve travel for meetings.