Appeals & Grievances Clinical Specialist

🔥 13 minutes ago

🗽 New York, North Dakota, +3 more states – Remote

🗽 New York – Remote 🌾 North Dakota – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote

💵 $83.1k - $120.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Finance • Medicare

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

• Receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances • Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider) • Processes appeals and grievances in accordance with internal company policy • Enters data into appropriate medical management services • Collaborates with other departments to thoroughly investigate appeal and grievances • Prepares for and participates in regulatory site visits • Additional duties as assigned

🎯 Requirements

• LPN or RN • Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management • Understanding 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 and Excel, as well as corporate email and virtual filing system (ie. Macess) • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

🏖️ Benefits

• medical, dental and vision coverage • incentive and recognition programs • life insurance • 401k contributions (all benefits are subject to eligibility requirements)