Appeals and Grievances Clinical Specialist

HealthFirst•Remote - NY, IN

1d•$73,400 - $120,360

About The Position

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances, and appeals concerning authorization or delivery of clinical and non-clinical services. It works with divisions across and outside the organization to resolve issues promptly and in compliance with applicable requirements. The A&G Clinical Specialist is the subject matter expert for clinical case development and resolution, ensuring compliance with federal and state regulations. The specialist manages an independent caseload, investigates and resolves member- or provider-initiated cases, and handles Department of Health and executive complaints as needed. The role may also include clinical claim appeals from participating and non-participating Healthfirst providers. The position may be remote or on-site at either 100 Church Street in New York City or 1101 Greenwood Avenue in Lake Mary, Florida. Attendance at A&G or Operations meetings and Town Halls may be required, and some meetings may involve travel to one of these locations. Travel and expenses are covered according to policy.

Requirements

RN, LPN, or Dental Hygienist qualification.
Ability to work independently with several computer applications, including Microsoft Word and Excel, corporate email, and a virtual filing system such as Macess.
Demonstrated ability to manage large caseloads and work effectively in a fast-paced environment.

Nice To Haves

Bachelor’s degree.
Clinical practice experience and experience in appeals and grievances, claims processing, utilization review, or utilization management/case management.
Demonstrated understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL, InterQual, Milliman, or Medicare local coverage guidelines.
Experience with care management systems such as CCMS, TruCare, and Hyland.

Responsibilities

Develop and resolve clinical cases involving pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services.
Research case issues and consult internal health plan policies and procedures to frame decisions.
Interpret regulations, resolve cases, and make critical decisions.
Update file documentation, including file notes and case summaries.
Manage case duties within regulatory timeframes.
Communicate effectively when handing off and picking up work from colleagues.
Meet productivity and quality expectations for the Specialist role.
Prepare cases for Medical Director review, ensuring the investigation has obtained and presented pertinent information, including case summaries, contract information, internal and external 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.
Manage Department of Health and executive complaints as needed.
Handle clinical claim appeals from participating and non-participating providers as needed.
Perform additional duties as assigned.