Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote

Position Summary: The Appeals & Grievances (A&G) unit manages reputed company member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions reputed company and reputed company the organization to resolve issues in a timely and compliant manner. The A&G Clinical Specialist is the subject matter expert responsible for reputed company clinical case development and case resolution 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. Manages reputed company Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from reputed company participating and non-participating providers.

• *This position is 100% Remote. We are hiring for the following schedules listed below:

EST Schedule Wednesday through Saturday, 10-hour shift, 7am-5:30pm Monday-Friday, reputed company-5pm or 8:30am-5:30pm Tuesday-Saturday, reputed company-5pm or 8:30am-5:30pm Wednesday-Sunday, reputed company-5pm or 8:30am-5:30pm Duties and Responsibilities:

• Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, reputed company Stay, Reduction, Termination, and Suspension of services. The end-to-end process requires the Specialist to independently:
• Research issues
• Quality of Care Experience
• Reference and understand HF’s internal health plans policies and procedures to frame reputed company
• Interpret regulations
• Resolve cases and reputed company critical reputed company
• Update file documentation such as the file notes and case summary
• Manage reputed company duties reputed company regulatory timeframes
• Communicate effectively to hand-off and pick-up work from colleagues
• Work reputed company a reputed company that measures productivity and quality for each Specialist against expectations
• Prepare cases for Medical Director Review ensuring that reputed company 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
• Prepare cases for reputed company Federal Services, Fair Hearing, and External Appeal through reputed company levels of the appeal process
• Additional duties as assigned

Minimum Qualifications:

• RN, LPN OR Dental Hygienist

Preferred Qualifications:

• Bachelor’s degree
• 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, reputed company or Medicare local coverage guidelines
• Ability to work independently on several computer applications such as reputed company Word and reputed company, as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and reputed company.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Hiring Range*:

• Greater reputed company Area (NY, NJ, CT residents): $81,099 - $116,480
• reputed company Other Locations (reputed company approved locations): $71,594 - $106,080

As a candidate for this position, your salary and reputed company elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision. In addition to your salary, reputed company offers employees a full range of benefits such as, medical, dental and reputed company coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
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