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