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Appeals and Grievances Nurse


Mid Level


Not defined

02 Jun → 02 Jul


New York, NY, USA

About Company

Healthfirst is a provider-sponsored health insurance company that serves more than 1.5 million members in downstate New York. Healthfirst offers top-quality Medicaid, Medicare Advantage, Child Health Plus, and Managed Long Term Care plans
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Job Description

The A&G Clinical Specialist RN or LPN is the subject matter expert responsible for all 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 all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers.

Job Responsibilities

  • 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.
  • 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
  • Work within a framework that measures productivity and quality for each Specialist against expectations
  • Prepare cases 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
  • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process
  • Additional duties as assigned

Requirements / Qualifications

  • RN or LPN
  • 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), 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

How To Apply

Apply through GoRemotely.

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