Appeals and Grievances Clinical Specialist

The Appeals & Grievances Clinical Specialist is 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, reference and understand HF's internal health plans policies and procedures to frame decisions, interpret regulations, resolve cases and make critical decisions.

Requirements

• RN
• 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

Benefits

• Medical, dental and vision coverage
• Incentive and recognition programs
• Life insurance
• 401k contributions