Appeals and Grievances Clinical Specialist

The Appeals & Grievances Clinical Specialist is responsible for case development and resolution of clinical cases, 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.

Requirements

• RN, LPN, or Dental Hygienist
• 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
• Experience with care management systems

Benefits

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