Remote Clinical Appeals Specialist

HealthFirst; Fulton (MS); Remote; USD 73,000 - 108,000; Full time

Job summary

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. You will manage your own caseload, prepare cases for Medical Director Review and external appeals, and handle DOH complaints as needed.

The role supports both remote and on-site work at designated locations, with travel as required for divisional meetings. Bachelor's degree and clinical licensing are preferred.

Qualifications

• RN, LPN or Dental Hygienist licensure required.
• Experience in appeals & grievances, claims processing, utilization review or utilization management.
• Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare guidelines.
• Ability to work independently across multiple computer applications (Word, Excel, email) and care management systems.

Responsibilities

• Develop and resolve clinical cases including pre-existing conditions, prior approvals, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services.
• Research issues, reference HF policies, interpret regulations, and document updates within regulatory timeframes.
• Prepare cases for Medical Director Review and for external appeals through the full appeal process.
• Handle additional duties as assigned and manage cases within deadlines.

Education

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring compliance with federal and state regulations. You will manage your own caseload, prepare cases for Medical Director Review and external appeals, and handle DOH complaints as needed.

The role supports both remote and on-site work at designated locations, with travel as required for divisional meetings. Bachelor's degree and clinical licensing are preferred.