A&G Clinical Specialist --Wednesday-Saturday Schedule
HealthFirst
Summary
The Appeals & Grievances (A&G) unit manages Healthfirst 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 within and outside the organization to resolve issues in a timely and compliant manner.
Job description
The A&G Clinical Specialist 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.
This position is 100% remote, working from home. Multiple Weekend Shifts options: 4 day work week, 10 hours a day on Friday to Monday or Wednesday to Saturday or Thursday to Sunday or Sunday to Wednesday; 5 day work week, 8 hours a day Tuesday to Saturday or Wednesday to Sunday or Sunday to Thursday.
Duties and 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
- RN or LPN
- Bachelor's degree (preferred)
- Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management (preferred)
- Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Milliman or Medicare local coverage guidelines (preferred)
- 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) (preferred)
- Experience with care management systems, such as CCMS, TruCare and Hyland (preferred)
- Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment (preferred)
Benefits
- Medical Coverage
- Dental Coverage
- Vision Coverage
- Incentive And Recognition Programs
- Life Insurance
- 401(k) Contributions
Company overview
HealthFirst is a medical equipment manufacturing company specializing in the development and production of healthcare devices and diagnostic equipment. As a medical device manufacturer, the company focuses on creating innovative solutions that enhance patient care and improve clinical outcomes. HealthFirst operates in the competitive medical technology sector, where it likely develops products ranging from diagnostic instruments to therapeutic devices used in various healthcare settings. The company's commitment to quality and regulatory compliance positions it as a reliable provider of medical equipment to hospitals, clinics, and healthcare facilities. With expertise in medical device engineering and manufacturing, HealthFirst contributes to advancing healthcare technology while maintaining rigorous standards for safety and efficacy. The company's products are designed to meet the evolving needs of healthcare professionals and patients, supporting improved diagnosis, treatment, and monitoring of medical conditions across different therapeutic areas.