Remote Clinical Appeals Specialist

Remote Jobs; New York (NY); À distance; USD 83 000 - 120 000; Plein temps

Résumé du poste

Healthfirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution. You will ensure compliance with federal/state regulations and handle DOH and executive complaints as needed. The role may be remote or on-site at NYC or Lake Mary locations, with travel as required.

You will independently research issues, interpret policies, prepare cases for review and external appeals, and maintain thorough documentation within regulatory timeframes.

Qualifications

• RN, LPN or Dental Hygienist licensed professional.
• Bachelor's degree preferred.
• Experience in appeals, grievances, or utilization review.
• Knowledge of ART 44/49 PHL, InterQual or Medicare guidelines.
• Proficient with Word/Excel and email; filing systems.

Responsabilités

• Develop and resolve clinical cases end-to-end, within regulatory timelines.
• Prepare cases for Medical Director Review and external appeals.
• Prepare materials for Maximus Federal Services and Fair Hearing.
• Manage a caseload and ensure accurate documentation.
• Communicate hand-offs and maintain case notes and summaries.

Connaissances

Regulatory knowledge

Case management

Communication

Research

Formation

RN, LPN or Dental Hygienist

Bachelor's degree (preferred)

Outils

Word

Excel

Macess

CCMS

TruCare

Hyland

Description du poste

Healthfirst seeks an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution. You will ensure compliance with federal/state regulations and handle DOH and executive complaints as needed. The role may be remote or on-site at NYC or Lake Mary locations, with travel as required.

You will independently research issues, interpret policies, prepare cases for review and external appeals, and maintain thorough documentation within regulatory timeframes.