Appeals and Grievances Clinical Specialist - RN or LPN - 100% 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.

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 timeframes 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 (i.e. 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