A&G Clinical Specialist

🔥 5 minutes ago

🦞 Maine, Montana, +8 more states – Remote

🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🗻 New Hampshire – Remote 🗽 New York – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🎸 Mississippi – Remote 🗿 South Dakota – Remote 🦬 Wyoming – Remote

💵 $73.4k - $108.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

📋 Description

• Manage clinical case development and case resolution for Appeals & Grievances cases • Ensure compliance with Federal and/or State regulations • Independently investigate and resolve member- or provider-initiated cases • Manage Department of Health and executive complaints as needed • Handle clinical claim appeals from participating and non-participating providers • Research issues and reference internal health plan policies and procedures • Interpret regulations and make critical case decisions • Update file documentation, including file notes and case summaries • Manage duties within regulatory timeframes • Communicate effectively to hand off and pick up work from colleagues • Work within productivity and quality expectations • Prepare cases for Medical Director Review with complete investigative information • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all appeal levels • Perform additional duties as assigned

🎯 Requirements

• RN or LPN • Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management • Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Milliman or Medicare local coverage guidelines • Ability to work independently on Microsoft Word and Excel, corporate email, and virtual filing systems such as Macess • Experience with care management systems such as CCMS, TruCare and Hyland • Demonstrated ability to manage large caseloads and work effectively in a fast-paced environment • Ability to work a Wednesday-Saturday, Thursday-Sunday, Friday-Monday, Sunday-Wednesday, Tuesday-Saturday, Wednesday-Sunday, or Sunday-Thursday schedule depending on selected shift • Work from home in one of the approved remote locations

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Competitive compensation and benefits package

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