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Healthfirst

We provide no-and low-cost health insurance in NYC, Long Island, Orange, Rockland, Sullivan, and Westchester counties.

Appeals & Grievances Clinical Specialist

Clinical SpecialistGeneralFull TimeRemoteSeniorTeam 1,001-5,000Since 1993H1B SponsorCompany SiteLinkedIn

Location

New York + 4 moreAll locations: New York | North Dakota | Virginia | West Virginia | Wisconsin

Posted

4 days ago

Salary

$83.1K - $120.4K / year

Seniority

Senior

English

Job Description

Appeals & Grievances Clinical Specialist

Healthfirst

• 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

Job 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)

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