Manager – Clinical Appeals and Grievances

Healthfirst

Manager of Clinical Appeals & Grievances overseeing specialists and case preparation for Healthfirst. Ensuring compliance, quality, and process optimization within the Appeals & Grievances operations.

Posted 7/29/2026full-timeRemote • New York, Tennessee, Virginia, West Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $88,400 - $149,430 per yearWebsite

Core Competencies

Role fit

Core Competencies

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

Demonstrates expertise in managing Appeals and Grievances processes, ensuring compliance with health plan policies and regulations while optimizing operational efficiency. Proven ability to lead teams, drive performance improvements, and effectively communicate with diverse stakeholders.

Highest-signal resume keywords

RN ExperienceUtilization ManagementAppeals And Grievance ProcessingPerformance ManagementRegulatory Interpretation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ResearchCPT Code PreparationProcess ImprovementCompliance ManagementGoal Management

Soft Skills

Independent ThinkingProblem SolvingRelationship BuildingCoachingCommunication

Tools & Technologies

Vendor Management SystemsCase Management Tools

Certifications & Qualifications

Bachelor's Degree

Industry Keywords

Health PlansOperational ChallengesBest PracticesQuality TargetsFast-Paced Environment

About the role

Key responsibilities & impact

Manages a team of specialists, with responsibility for goal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned
Provides oversight in case research and provides advice as needed
Understands HF’s internal health plans’ policies and procedures to frame decisions
Interprets regulations to provide guidance to specialists on a daily basis
Ensures the timely resolution of cases and makes critical decisions
Focuses on clinical criteria for expedited cases
Helps standardize and optimize how Appeals and Grievances are routed
Determine best practices and strategically deploy approaches to meet production, compliance and quality targets
Works with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
Provides guidance in the preparation of case preparation 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
Has oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
Assists in leading the AOR / WOL Outreach team in coordination with the supervisor
Works with Providers and DSE on educating providers in how to submit Appeals timely and accurately.
Maintains delegated vendor relationship and ensure vendor performance and compliance measures are met
Institutes and manages working relationships within various operational areas to identify and execute overall process improvements
Diagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team
Identifies trends and recommends solutions for improvement.
Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functions
Maintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancements
Additional duties as assigned

Requirements

What you’ll need

Bachelor's degree from an accredited institution or equivalent work experience
RN Experience with utilization management or appeals and grievance processing and compliance
Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams
Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions
Experience preparing and delivering written and verbal information to multiple types of audiences
Demonstrated ability to build and foster effective relationships.

Benefits

Comp & perks

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions