NY Licensed Appeals Specialist

Managing clinical case development and resolution, the full-time NY Licensed Appeals Specialist will investigate and resolve member or provider complaints and appeals regarding clinical services while working remotely. Key responsibilities Develop and resolve clinical cases related to pre-existing conditions, prior approvals, and medical necessity while adhering to regulatory timeframes Prepare cases for Medical Director Review and external appeal processes, ensuring all pertinent information is accurately documented Collaborate with internal and external stakeholders to effectively manage a caseload and communicate case updates Required qualifications Current RN, LPN, or Dental Hygienist license Experience in clinical practice with a focus on appeals & grievances, claims processing, or utilization management Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL Proficiency in Microsoft Word and Excel, as well as experience with care management systems Ability to manage large caseloads in a fast-paced environment