Clinical Appeals Specialist - NY

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist.

Key Responsibilities

• Manage clinical case development and resolution, ensuring compliance with regulations
• Prepare cases for Medical Director Review and external appeals
• Handle all Department of Health and executive complaints as needed

Required Qualifications

• RN, LPN, or Dental Hygienist license
• Bachelor's degree preferred
• Experience in clinical practice related to appeals and grievances or utilization management
• Understanding of Utilization Review Guidelines and related standards
• Ability to manage large caseloads in a fast-paced environment