The Appeals & Grievances Clinical Specialist is responsible for receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances.
Duties and Responsibilities:
- 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.
Minimum Qualifications:
- LPN or RN
Preferred Qualifications:
- 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
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@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.
All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Hiring Range*:
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Greater New York City Area (NY, NJ, CT residents): $83,100 – $120,360
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All Other Locations (within approved locations): $73,400 – $108,160
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
Additional Information
Company: Healthfirst
Location: New York, West Virginia, North Dakota, Wisconsin, Indiana, Virginia, Texas, Tennessee, South Carolina, Pennsylvania, Ohio, Nevada, New Jersey, North Carolina, Minnesota, Maryland, Massachusetts, Florida, Delaware, Connecticut, New Hampshire, Arizona, Vermont, Alabama, Maine, Wyoming, Montana, South Dakota, Nebraska, New Mexico, Washington, Michigan, Hawaii, Oklahoma
Salary: $83,100 – $120,360 per year
Job ID: R022050
Specialties: Case Manager, Appeals Nurse, Utilization Review, Utilization Management
Required Licenses: RN, LPN/LVN
Experience Level: No Experience
