Appeals and Grievances Clinical Specialist

🕒 October 21

🦌 Connecticut, Florida, +14 more states – Remote

🦌 Connecticut – Remote 🐊 Florida – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌾 North Dakota – Remote 🌪️ Oklahoma – Remote 🎸 Mississippi – Remote 🗿 South Dakota – Remote ⛷️ Utah – 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.

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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 Healthfirst member complaints, grievances and appeals related to authorization or delivery of clinical and non-clinical services • Serve as subject matter expert for clinical case development and case resolution while ensuring compliance with Federal and/or State regulations • Independently manage a caseload and 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 Healthfirst providers as needed • Research issues and reference internal health plan policies and procedures to frame decisions • Interpret regulations and resolve cases using critical decision-making • 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 investigation information, including case summaries, contract information, responses, diagnoses, and CPT codes and descriptions • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process • Perform additional duties as assigned

🎯 Requirements

• RN, LPN OR Dental Hygienist • 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), InterQual, Milliman or Medicare local coverage guidelines • Ability to work independently on several computer applications such as Microsoft Word and Excel, corporate email and virtual filing system (ie. Macess) • Experience with care management systems, such as CCMS, TruCare and Hyland • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment • Applicants must live in an approved location listed for the posting; approved locations include New York, Louisiana, North Dakota, Indiana, Utah, Mississippi, Wyoming, Montana, South Dakota, Nebraska, New Hampshire, New Mexico, Maine, and Oklahoma • Candidates residing in the Greater New York City Area must be residents of New York, New Jersey, or Connecticut

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Incentive and recognition programs • Life insurance • 401k contributions (all benefits are subject to eligibility requirements) • Travel and expense reimbursement according to policy for required attendance at certain divisional meetings and Town Halls • Competitive compensation and benefits package

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