Appeals and Grievances Clinical Specialist - RN or LPN, 100% Remote
About the position Responsibilities • Research issues related to clinical cases. • Reference and understand internal health plans policies and procedures to frame decisions. • Interpret regulations and resolve cases, making critical decisions. • Update file documentation, including file notes and case summaries. • 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 against expectations. • Prepare cases for Medical Director Review, ensuring all pertinent information is obtained and presented. • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process. • Perform additional duties as assigned. Requirements • Registered Nurse (RN), Licensed Practical Nurse (LPN), or Dental Hygienist certification required. • Experience in clinical practice with appeals & grievances, claims processing, utilization review, or case management. Nice-to-haves • Bachelor's degree preferred. • Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman, or Medicare local coverage guidelines. • Ability to work independently on various computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing systems (e.g., Macess). • Experience with care management systems such as CCMS, TruCare, and Hyland. • Demonstrated ability to manage large caseloads in a fast-paced environment. Apply tot his job