Remote Clinical Appeals & Grievances Specialist

HealthFirst; Portland (ME); Hybrid; USD 73,000 - 108,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401k contributions

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage a caseload of member and provider cases, ensuring compliant resolution in a timely manner. You will develop clinical cases, prepare documents for Medical Director Review, and coordinate with Maximus and external appeals.

Ideal candidates have RN, LPN or Dental Hygienist credentials, familiarity with NY ART 44/49 PHL and utilization guidelines, and the ability to work independently across multiple computer systems in a

Qualifications

• RN, LPN or Dental Hygienist credential required.
• Experience in appeals and grievances is preferred.
• Knowledge of NYS ART 44/49 PHL, InterQual, Milliman or Medicare guidelines is preferred.
• Ability to use Word, Excel, email and a filing system.
• Ability to manage large caseloads in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases, including medical necessity, pre-certification, continued stay, and terminations.
• Prepare cases for Medical Director Review, Maximus Federal Services, Fair Hearing and External Appeal.
• Additional duties as assigned.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor’s degree

Tools

Microsoft Word

Excel

Macess

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage a caseload of member and provider cases, ensuring compliant resolution in a timely manner. You will develop clinical cases, prepare documents for Medical Director Review, and coordinate with Maximus and external appeals.

Ideal candidates have RN, LPN or Dental Hygienist credentials, familiarity with NY ART 44/49 PHL and utilization guidelines, and the ability to work independently across multiple computer systems in a