Remote Clinical Appeals Specialist

Healthfirst; Texas; Remote; USD 73,000 - 108,000; Full time

Job summary

Healthfirst is seeking an experienced A&G Clinical Specialist to independently manage clinical case development and resolution for member complaints, grievances and appeals. This remote role supports compliant handling of DOH and executive complaints and may involve preparing cases for external appeal processes.

The position emphasizes strong research, regulatory interpretation, and ability to manage large caseloads while delivering timely resolutions in a remote work setting.

Qualifications

• RN or LPN certification or license is required.
• Bachelor’s degree preferred as listed under qualifications.
• Experience in appeals & grievances, claims processing, utilization review or management is desirable.

Responsibilities

• Develop and resolve clinical cases, including pre-existing conditions, prior approvals and medical necessity.
• Prepare cases for Medical Director Review and for external appeal processes.
• Manage caseloads within regulatory timeframes and document case progress clearly.
• Communicate effectively to hand off work and coordinate with team members.

Skills

RN or LPN

Independent work

Fast-paced environment

Education

Bachelor’s degree

Tools

CCMS

TruCare

Hyland

Macess

Microsoft Word

Excel

Corporate email system

Job description

Healthfirst is seeking an experienced A&G Clinical Specialist to independently manage clinical case development and resolution for member complaints, grievances and appeals. This remote role supports compliant handling of DOH and executive complaints and may involve preparing cases for external appeal processes.

The position emphasizes strong research, regulatory interpretation, and ability to manage large caseloads while delivering timely resolutions in a remote work setting.