A&G Clinical Specialist

Position Summary: 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

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360

• 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.

73400-108160