Remote Clinician - Appeals & Grievances Specialist

HealthFirst; Sioux Falls (SD); Hybrid; USD 83,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401k contributions

Job summary

HealthFirst is seeking an Appeals & Grievances (A&G) Clinical Specialist to serve as the subject matter expert for clinical case development and resolution while ensuring compliance with federal and state regulations.

The role may be remote or on-site at either the New York City or Lake Mary locations, with occasional travel per policy. Responsibilities include case development, handling DOH and executive complaints, and preparing cases for Medical Director Review within required timeframes.

Qualifications

• RN, LPN or Dental Hygienist license/certification.
• Bachelor's degree required.
• Experience in appeals/grievances, claims processing, utilization review or utilization management.
• Understanding of Utilization Review Guidelines (NYS ART 44/49 PHL), InterQual, Milliman or Medicare guidelines.

Responsibilities

• Develop and resolve clinical cases with supporting documentation and regulatory compliance.
• Manage DOH and executive complaints as needed.
• Prepare cases for Medical Director Review with complete case summaries and CPT codes.
• Meet regulatory timeframes and maintain productivity/quality metrics.

Skills

RN

LPN

Dental Hygienist

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Job description

HealthFirst is seeking an Appeals & Grievances (A&G) Clinical Specialist to serve as the subject matter expert for clinical case development and resolution while ensuring compliance with federal and state regulations.

The role may be remote or on-site at either the New York City or Lake Mary locations, with occasional travel per policy. Responsibilities include case development, handling DOH and executive complaints, and preparing cases for Medical Director Review within required timeframes.