Remote Clinical Appeals & Grievances Specialist

Remote Jobs; United States; Hybrid; USD 73,000 - 120,000; Full time

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution while ensuring compliance with federal and state regulations. The role supports cases from Healthfirst and external providers, with remote or on-site work at NY or FL campuses.

You will handle DOH and executive complaints and participate in divisional meetings; travel may be required. The position emphasizes independent caseload management, timely investigation, and accurate

Qualifications

• RN, LPN, and Dental Hygienist credentials required.
• Experience in appeals & grievances, claims processing, utilization review or utilization management.
• Familiarity with Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
• Proficient with Microsoft Word and Excel, corporate email and document management systems (e.g., Macess).
• Ability to manage large caseloads and work in a fast-paced environment.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions and medical necessity.
• Research issues and interpret regulations to frame decisions.
• Prepare cases for Medical Director Review with all pertinent information.
• Prepare cases for external appeal through all levels of the process.
• Manage file documentation and regulatory timeframes; communicate for hand-offs.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution while ensuring compliance with federal and state regulations. The role supports cases from Healthfirst and external providers, with remote or on-site work at NY or FL campuses.

You will handle DOH and executive complaints and participate in divisional meetings; travel may be required. The position emphasizes independent caseload management, timely investigation, and accurate