Appeals & Grievances Clinical Specialist

Healthfirst

Clinical Specialist responsible for handling member and provider clinical appeals and grievances at Healthfirst. Collaborating with various departments to ensure proper processing and investigation of cases.

Posted 7/6/2026full-timeRemote • New York, North Dakota, Virginia, West Virginia, Wisconsin • 🇺🇸 United StatesMid-LevelSenior💰 $83,100 - $120,360 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in clinical appeals and grievances management, ensuring compliance with Utilization Review Guidelines and effective data management. Proficient in collaborating across departments to resolve complex cases while managing large caseloads in a fast-paced environment.

Highest-signal resume keywords

LPNRNClinical Appeals ManagementUtilization Review GuidelinesClaims Processing

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical PracticeAppeals ProcessingGrievance ManagementUtilization ReviewData Entry

Soft Skills

Independent WorkCollaborationTime Management

Tools & Technologies

Microsoft WordMicrosoft ExcelCorporate EmailVirtual Filing SystemMacess

Certifications & Qualifications

LPNRN

Industry Keywords

NYS ART 44NYS ART 49 PHLInterQualMedicare Guidelines

About the role

Key responsibilities & impact

Receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances
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

Requirements

What you’ll need

LPN or RN
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

Benefits

Comp & perks

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions (all benefits are subject to eligibility requirements)