Remote Clinical Appeals Specialist (RN/LPN)

HFMS HF Management Services, LLC; New York (NY); Híbrido; USD 83.000 - 120.000; Jornada completa

Descripción de la vacante

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring regulatory compliance. The role requires handling a personal caseload and addressing DOH and executive complaints.

The position is 100% remote with weekend shift options and a focus on pre-certification, medical necessity, and appeal processes across levels.

Formación

• RN or LPN licensed.
• Bachelor’s degree preferred.
• Experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
• Familiarity with NY ART 44/49 PHL, Milliman or Medicare local coverage guidelines.
• Proficient with Word and Excel, email and filing systems.
• Experience with care management systems such as CCMS, TruCare and Hyland.
• Ability to manage large caseloads in a fast-paced environment.

Responsabilidades

• Responsible for case development and resolution of clinical cases, such as pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, suspension of services.
• Research issues and interpret regulations to frame decisions.
• Prepare cases for Medical Director Review with complete documentation.
• Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process.

Conocimientos

RN or LPN

Independent work

Microsoft Word/Excel

Educación

Bachelor’s degree

Herramientas

CCMS

TruCare

Hyland

Microsoft Word/Excel

Descripción del empleo

Healthfirst is seeking an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution while ensuring regulatory compliance. The role requires handling a personal caseload and addressing DOH and executive complaints.

The position is 100% remote with weekend shift options and a focus on pre-certification, medical necessity, and appeal processes across levels.