Remote Clinical Appeals Specialist

HealthFirst; Jackson (MS); Hybrid; USD 73,000 - 108,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Life insurance

401k contributions

Incentive and recognition programs

Job summary

HealthFirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution while ensuring compliance with federal and state regulations. The role involves handling DOH and executive complaints, managing caseloads, and coordinating with external appeal processes.

Remote or on-site options are available at multiple locations. Ideal candidates have RN, LPN, or Dental Hygienist qualifications, with preferred experience in utilization management and familiarity with NY ART

Qualifications

• RN, LPN or Dental Hygienist required.
• Experience in appeals & grievances, claims processing, utilization review or case management preferred.
• Knowledge of Utilization Review Guidelines (NYS ART 44/49) and local coverage guidelines advantageous.

Responsibilities

• Develop and resolve clinical cases, including prior approvals, medical necessity, pre-certification and continued stay decisions.
• Research issues and reference internal policies to frame decisions.
• Prepare cases for Medical Director Review and external appeals. Manage caseloads to regulatory timeframes.
• Document case notes and summaries, and communicate clearly to colleagues and stakeholders.
• Attend meetings and town halls as required; occasional travel may be needed.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

CCMS

TruCare

Hyland

Job description

HealthFirst is seeking an A&G Clinical Specialist to manage clinical case development and resolution while ensuring compliance with federal and state regulations. The role involves handling DOH and executive complaints, managing caseloads, and coordinating with external appeal processes.

Remote or on-site options are available at multiple locations. Ideal candidates have RN, LPN, or Dental Hygienist qualifications, with preferred experience in utilization management and familiarity with NY ART