Remote Clinical Appeals & Grievances Specialist

Healthfirst; New York (NY); Remote; USD 73,000 - 120,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Life insurance

401k contributions

Job summary

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with federal/state regulations. The role may be remote or on-site at NYC or Lake Mary, with travel as needed.

The position requires licensure as RN, LPN, or Dental Hygienist, and experience in appeals, grievances, and utilization review. A strong ability to manage large caseloads in a fast-paced environment is essential.

Qualifications

• Minimum qualifications include RN, LPN, or Dental Hygienist licensure.
• Experience with appeals & grievances, claims processing, utilization review or case management is preferred.
• Demonstrated ability to manage large caseloads in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases including prior approvals, medical necessity, pre-certification and continued stay.
• Prepare cases for Medical Director Review and external appeal processes.
• Manage DOH and executive complaints and maintain accurate case documentation within regulatory timeframes.
• Communicate effectively with colleagues during hand-offs and ensure complete case information.

Skills

Independent work

Multitasking

Advanced computer skills

Microsoft Word

Microsoft Excel

Email systems

Macess

CCMS

TruCare

Hyland

Education

RN, LPN or Dental Hygienist

Tools

Microsoft Word

Microsoft Excel

Email

Macess

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution, ensuring compliance with federal/state regulations. The role may be remote or on-site at NYC or Lake Mary, with travel as needed.

The position requires licensure as RN, LPN, or Dental Hygienist, and experience in appeals, grievances, and utilization review. A strong ability to manage large caseloads in a fast-paced environment is essential.