Remote Clinical Appeals Strategist

HealthFirst; Butlerville (IN); Hybrid; USD 83,000 - 120,000; Full time

Job summary

Healthfirst seeks an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution in a compliant, timely manner. You will manage DOH and executive complaints and may handle clinical claim appeals from providers.

The role requires experience in utilization review/case management and the ability to work across multiple computer applications, including Word and Excel, with secure email and filing systems. Remote or on-site work is available.

Qualifications

• RN, LPN or Dental Hygienist credential required.
• Bachelor’s degree required.
• Experience in clinical practice with appeals & grievances, claims processing, utilization review or utilization management/case management.
• Demonstrated understanding of Utilization Review Guidelines (e.g., NYS ART 44/49 PHL), InterQual, Milliman or Medicare local coverage guidelines.
• Ability to work independently using Word/Excel and corporate email with a secure filing system.

Responsibilities

• Manage clinical case development and resolution with adherence to regulatory timeframes.
• Prepare cases for Medical Director Review with complete case summaries and relevant documents.
• Ensure compliance with internal policies and external regulations in all actions.
• Coordinate with Healthfirst stakeholders to address complaints, appeals and grievances.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor’s degree

Tools

Microsoft Word

Excel

Corporate email

Virtual filing system

Job description

Healthfirst seeks an Appeals & Grievances Clinical Specialist to lead clinical case development and resolution in a compliant, timely manner. You will manage DOH and executive complaints and may handle clinical claim appeals from providers.

The role requires experience in utilization review/case management and the ability to work across multiple computer applications, including Word and Excel, with secure email and filing systems. Remote or on-site work is available.