Remote Clinical Appeals & Grievances Specialist

HealthFirst; New Hampshire; Hybrid; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Life insurance

401k contributions

Job summary

HealthFirst's Appeals & Grievances (A&G) unit seeks a Clinical Specialist to develop and resolve clinical cases, manage DOH and executive complaints, and handle complex appeals from providers. This role may be remote or on-site at NY or Lake Mary, FL locations, with travel to divisional meetings as needed.

The candidate will ensure adherence to federal/state regulations and internal HF policies. You will review case details, coordinate with Medical Directors, and maintain timely communications

Qualifications

• Experience in appeals & grievances, claims processing, utilization review or case management.
• Knowledge of Utilization Review Guidelines (NYS ART 44 and 49 PHL) and other guidelines.
• Ability to work independently across Word, Excel, email and filing systems.

Responsibilities

• Prepare cases for Medical Director Review with complete summaries, contract details and CPT codes.
• Manage duties within regulatory timeframes and quality standards.
• Work within a productivity and quality framework with defined metrics.
• Reference HF policies and procedures to frame clinical decisions.
• Attend divisional meetings and town halls as required.

Skills

Clinical appeals & grievances

Claims processing

Utilization review / case management

Independent work across applications

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Corporate email / filing systems

Job description

HealthFirst's Appeals & Grievances (A&G) unit seeks a Clinical Specialist to develop and resolve clinical cases, manage DOH and executive complaints, and handle complex appeals from providers. This role may be remote or on-site at NY or Lake Mary, FL locations, with travel to divisional meetings as needed.

The candidate will ensure adherence to federal/state regulations and internal HF policies. You will review case details, coordinate with Medical Directors, and maintain timely communications