Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - Remote

Position Summary:

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers.

• Wednesday through Saturday, 10-hour shift, 7am-5:30pm
• Monday-Friday, 8am-5pm or 8:30am-5:30pm
• Tuesday-Saturday, 8am-5pm or 8:30am-5:30pm
• Wednesday-Sunday, 8am-5pm or 8:30am-5:30pm

• Responsible for case development and resolution of clinical cases such as pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services. The end-to-end process requires the Specialist to independently:
  • Research issues
  • Quality of Care Experience
  • Reference and understand HF’s internal health plans policies and procedures to frame decisions
  • Interpret regulations
  • Resolve cases and make critical decisions
  • Update file documentation such as the file notes and case summary
  • Manage all duties within regulatory time frames
  • Communicate effectively to hand-off and pick-up work from colleagues
  • Work within a framework that measures productivity and quality for each Specialist against expectations
• Prepare cases for Medical Director Review ensuring that all pertinent information (case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case.
• Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process.
• Additional duties as assigned.

• RN, LPN OR Dental Hygienist

• Bachelor’s degree
• 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), Inter Qual, Milliman or Medicare local coverage guidelines.
• Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (i.e., Macess). Experience with care management systems, such as CCMS, Tru Care and Hyland.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis.

HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers or calling . In your email please include a…