Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote

Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote

Join to apply for the Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote role at Healthfirst .

Position Summary: The Appeals & Grievances (A&G) unit manages member complaints, grievances, and appeals related to clinical and non-clinical services. The A&G Clinical Specialist is responsible for clinical case development and resolution, ensuring compliance with regulations. The role involves managing caseloads, investigating cases, and handling complaints from the Department of Health and external parties. The specialist may also handle clinical claim appeals from providers.

This position is 100% Remote. We are hiring for the following schedules:

• EST Schedule: Wednesday through Saturday, 10-hour shift, 7am-5:30pm
• Monday-Friday: 8am-5pm or 8:30am-5:30pm
• Tuesday-Saturday: 8am-5pm or 8:30am-5:30pm
• Wednesday-Sunday: 8am-5pm or 8:30am-5:30pm

Duties and Responsibilities:

• Develop and resolve clinical cases such as pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services.
• Research issues, interpret regulations, and reference internal policies.
• Make decisions, document cases, and manage work within regulatory timeframes.
• Communicate effectively with colleagues and prepare cases for review and appeals.

Minimum Qualifications:

• RN, LPN, or Dental Hygienist

Preferred Qualifications:

• Bachelor’s degree
• Experience in clinical practice, appeals & grievances, claims processing, utilization review, or case management.
• Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare guidelines.
• Proficiency with Microsoft Word, Excel, email, and virtual filing systems; experience with care management systems like CCMS, TruCare, Hyland.
• Ability to manage large caseloads in a fast-paced environment.

Hiring Range:

• Greater NYC Area (NY, NJ, CT): $81,099 - $116,480
• Other locations: $71,594 - $106,080

Salary depends on experience, education, licenses, and other factors. Benefits include medical, dental, vision, life insurance, 401k, and more.

Additional Details:

• Employment type: Full-time
• Job function: Healthcare Provider
• Industries: Hospitals and Healthcare