Appeals & Grievances Clinical Specialist

Position Summary The Appeals & Grievances Clinical Specialist is responsible for receiving, investigating, and responding verbally and in writing to member and provider clinical appeals and grievances. Responsibilities Ensure appeals and grievances are properly classified (e.g., denial of service, denial of payment, or a grievance about a provider). Process appeals and grievances in accordance with internal company policy. Enter data into the appropriate medical management services systems. Collaborate with other departments to thoroughly investigate appeals and grievances. Prepare for and participate in regulatory site visits. Perform additional duties as assigned. Minimum Qualifications LPN or RN license. Preferred Qualifications Experience in clinical practice with involvement in appeals & grievances, claims processing, utilization review, or case management. Knowledge of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual or Medicare Guidelines. Ability to work independently on several computer applications such as Microsoft Word, Excel, corporate email, and virtual filing system (e.g., Macess). Demonstrated ability to manage large caseloads and work effectively in a fast‑paced environment. Equal Opportunity Employer We are an equal opportunity employer. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC will not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified. If you have a disability under the Americans with Disabilities Act or a similar law and need a reasonable accommodation to assist with your job search or application, please contact us by emailing View email address on click.appcast.io or calling View phone number on click.appcast.io. Include a description of the accommodation you are requesting and a description of the position for which you are applying. Salary & Benefits Salary range: Greater New York City Area – $83,100 to $120,360; Other approved locations – $73,400 to $108,160. Benefits include medical, dental, vision coverage, incentive and recognition programs, life insurance, and 401k contributions (subject to eligibility). #J-18808-Ljbffr Healthfirst