Senior Clinical Appeals & Grievances Specialist (Remote)

HealthFirst; North Dakota; A distancia; USD 83.000 - 120.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental & vision

401(k) contributions

Descripción de la vacante

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to develop and resolve complex clinical cases. You will ensure compliance with federal and state regulations while handling DOH and executive complaints as needed.

The role offers remote or on-site work at NY or FL locations, with travel to divisional meetings; candidates should have a bachelor’s degree and background in appeals, utilization review, or case management.

Formación

• Bachelor’s degree required with experience in appeals and grievances, claims processing, or utilization management.
• Ability to develop clinical cases and resolve them within regulatory timeframes.
• Familiarity with Utilization Review guidelines (e.g., NY ART 44/49) and related standards.

Responsabilidades

• Develop and resolve clinical cases, including pre-authorization and medical necessity decisions.
• Ensure timely handling within regulatory timeframes and maintain quality metrics.
• Prepare case materials for Medical Director Review with complete documentation.

Conocimientos

Clinical case development

Regulatory compliance

Independent work approach

Communication skills

Educación

Bachelor’s degree

Herramientas

Microsoft Word

Microsoft Excel

HF Management Services system

Descripción del empleo

HealthFirst is seeking an Appeals & Grievances Clinical Specialist to develop and resolve complex clinical cases. You will ensure compliance with federal and state regulations while handling DOH and executive complaints as needed.

The role offers remote or on-site work at NY or FL locations, with travel to divisional meetings; candidates should have a bachelor’s degree and background in appeals, utilization review, or case management.