Remote Clinical Appeals Specialist

HealthFirst; Clayton (NM); Hybride; USD 73 000 - 108 000; Plein temps

Résumé du poste

HealthFirst is seeking an A&G Clinical Specialist to independently develop and resolve clinical cases, ensuring compliance with federal/state regulations. You will manage your own caseload, handle DOH and executive complaints, and may process clinical claim appeals from providers.

The role supports remote or on-site work at specified locations, requires knowledge of utilization review guidelines, and involves preparing materials for reviews and external appeals while meeting tight deadlines.

Qualifications

• RN, LPN or Dental Hygienist credential required.
• Bachelor’s degree preferred for advancement in the role.
• Experience in appeals, grievances, claims processing or utilization management.

Responsabilités

• Develop and resolve clinical cases; research issues and interpret regulations.
• Prepare cases for Medical Director Review, Maximus Federal Services and External Appeal.
• Manage caseload and communicate with team while meeting regulatory timelines.

Connaissances

MS Word

MS Excel

Corporate email

Virtual filing system

Formation

RN, LPN OR Dental Hygienist

Outils

CCMS

TruCare

Hyland

Macess

Description du poste

HealthFirst is seeking an A&G Clinical Specialist to independently develop and resolve clinical cases, ensuring compliance with federal/state regulations. You will manage your own caseload, handle DOH and executive complaints, and may process clinical claim appeals from providers.

The role supports remote or on-site work at specified locations, requires knowledge of utilization review guidelines, and involves preparing materials for reviews and external appeals while meeting tight deadlines.