Position Summary:
The Appeals & Grievances Clinical Specialist is responsible for receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances.
Duties and Responsibilities:
- Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider)
- Processes appeals and grievances in accordance with internal company policy
- Enters data into appropriate medical management services
- Collaborates with other departments to thoroughly investigate appeal and grievances.
- Prepares for and participates in regulatory site visits.
- Additional duties as assigned.
Minimum Qualifications:
- LPN or RN
Preferred Qualifications:
- Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.
- Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual or Medicare 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).
- Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.
If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [email protected] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC.