Appeals and Grievances Clinical Specialist

🔥 16 hours ago

🏈 Alabama, Arizona, +34 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🦬 Wyoming – Remote

💵 $73.4k - $120.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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

• Develop and resolve clinical cases involving pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services • Research issues and reference internal health plan policies and procedures • Interpret regulations and make critical case-resolution decisions • Update file notes and case summaries • Manage duties within regulatory timeframes • Communicate effectively to hand off and pick up work from colleagues • Meet productivity and quality expectations • Prepare cases for Medical Director Review with complete case summaries, contract information, responses, diagnoses, and CPT codes and descriptions • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all appeal levels • Manage an individual caseload • Manage Department of Health and executive complaints as needed • Handle clinical claim appeals from participating and non-participating providers as needed • Attend A&G/Operations divisional meetings and Town Halls, with occasional travel to designated locations

🎯 Requirements

• RN, LPN, or Dental Hygienist • Bachelor’s degree preferred • 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 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

🏖️ Benefits

• Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Travel and expenses covered according to policy for required meetings • Competitive compensation and benefits package