Appeals and Grievances Clinical Specialist – Quality of Care

Healthfirst

A&G Clinical Specialist managing Healthfirst member complaints, grievances and appeals. Responsible for clinical case development and ensuring compliance with regulations while resolving issues.

Posted 7/22/2026full-timeNew York City • Florida, New York • 🇺🇸 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 case development and resolution, with a strong understanding of Utilization Review Guidelines and experience in managing large caseloads. Proficient in utilizing care management systems and effectively communicating within a fast-paced environment.

Highest-signal resume keywords

RN PreferredQuality Of Care ExperienceUtilization Review GuidelinesCare Management SystemsCase Management

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Case DevelopmentCase ResolutionClaims ProcessingUtilization ReviewGrievances ManagementDocumentation ManagementCritical Decision MakingRegulatory Compliance

Soft Skills

Effective CommunicationIndependent WorkTime Management

Tools & Technologies

Microsoft WordMicrosoft ExcelMacessCCMSTruCareHyland

Certifications & Qualifications

Bachelor's Degree

Industry Keywords

Health Plans PoliciesNYS ART 44NYS ART 49 PHLInterQualMillimanMedicare Local Coverage Guidelines

About the role

Key responsibilities & impact

Responsible for case development and resolution of clinical cases
Research issues
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
Prepare cases for Medical Director Review ensuring that all pertinent information has been obtained

Requirements

What you’ll need

RN Preferred
Bachelor’s degree
Quality of Care 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), InterQual, 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, (ie. Macess).
Experience with care management systems, such as CCMS, TruCare and Hyland.
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