Remote Clinical Appeals Specialist (A&G)

Healthfirst; New York (NY); Remote; USD 83,000 - 120,000; Full time

Job summary

Healthfirst is seeking a remote A&G Clinical Specialist to manage appeals, grievances and clinically develop cases from home. The role supports pre-authorization, medical necessity, and continued stay decisions, with independent case investigation and regulatory compliance.

Weekend and 5-day shift options are available, enabling flexible coverage. The position requires RN or LPN licensure and a Bachelor’s degree; experience in clinical practice with appeals, utilization review, and care

Qualifications

• RN or LPN license required for clinical expertise.
• Bachelor’s degree preferred.
• Experience in appeals, grievances, claims processing, or utilization review.
• Familiarity with NY ART 44/49 PHL, Milliman or Medicare local guidelines.

Responsibilities

• Develop and resolve clinical cases from initiation to closure.
• Research issues and interpret regulations to support decisions.
• Prepare documentation for Medical Director Review and external appeals.
• Manage caseload within regulatory timeframes and maintain case notes.

Skills

Clinical case development

Appeals & grievances

Case management

Regulatory interpretation

Microsoft Word & Excel

CCMS TruCare Hyland

Education

Bachelor’s degree

RN or LPN license

Tools

Microsoft Word

Microsoft Excel

Email systems

Macess filing system

CCMS

TruCare

Hyland

Job description

Healthfirst is seeking a remote A&G Clinical Specialist to manage appeals, grievances and clinically develop cases from home. The role supports pre-authorization, medical necessity, and continued stay decisions, with independent case investigation and regulatory compliance.

Weekend and 5-day shift options are available, enabling flexible coverage. The position requires RN or LPN licensure and a Bachelor’s degree; experience in clinical practice with appeals, utilization review, and care