Remote Clinical Appeals & Grievances Specialist

Healthfirst; United States; Remote; USD 73,000 - 108,000; Full time

Job summary

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution for member and provider appeals and grievances. This 100% remote role involves independent investigation, regulatory compliance, and timely case closure while handling a diverse caseload.

The position requires RN or LPN licensure and a preference for a Bachelor’s degree; strong experience with utilization review and care management systems is a plus.

Qualifications

• RN or LPN licensure is required.
• Bachelor’s degree preferred.
• Experience in appeals, grievances, claims processing, utilization review or case management preferred.
• Ability to work independently across multiple computer applications (Word, Excel, email, filing systems).
• Experience with care management systems (CCMS, TruCare, Hyland) is a plus.
• Ability to manage large caseloads in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases end-to-end (Pre-existing conditions, Prior approvals, Medical necessity, Pre-certification, Continued stay, Termination, Suspension).
• Research issues and reference HF policies to frame decisions.
• Interpret regulations and ensure compliance within regulatory timeframes.
• Prepare cases for Medical Director Review and external appeals.
• Update case notes and summaries; hand off work as needed.

Skills

Appeals & grievances knowledge

Clinical case development

Regulatory compliance

Independent work

Regulatory timeframes

Education

RN or LPN licensure

Bachelor’s degree

Tools

Microsoft Word

Excel

Corporate email

Macess

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution for member and provider appeals and grievances. This 100% remote role involves independent investigation, regulatory compliance, and timely case closure while handling a diverse caseload.

The position requires RN or LPN licensure and a preference for a Bachelor’s degree; strong experience with utilization review and care management systems is a plus.