Remote Clinical Appeals Specialist

HealthFirst; Oregon; 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. The role requires independent case investigation, adherence to regulations, and coordination with Medical Director Review and external appeal processes.

The position may be remote or on-site at NY or Lake Mary, FL locations, with travel as needed. Responsibilities include researching issues, referencing internal policies, interpreting regulations, and maintaining documentation

Qualifications

• Must hold RN, LPN, or Dental Hygienist license.
• Experience with appeals & grievances, claims processing, utilization review or utilization management/case management is preferred.
• Ability to work independently across multiple computer applications (Word, Excel, email, filing systems).

Responsibilities

• Develop and resolve clinical case theories and documentation.
• Prepare cases for Medical Director Review and external appeal processes.
• Manage caseload within regulatory timeframes and communicate updates effectively.
• Perform other duties as assigned by supervisor.

Education

RN, LPN OR Dental Hygienist

Job description

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to manage clinical case development and resolution. The role requires independent case investigation, adherence to regulations, and coordination with Medical Director Review and external appeal processes.

The position may be remote or on-site at NY or Lake Mary, FL locations, with travel as needed. Responsibilities include researching issues, referencing internal policies, interpreting regulations, and maintaining documentation