New York Clinical Specialist

Job Summary

A company is looking for a Clinical Specialist.

Key Responsibilities

• Receive, investigate, and respond to member and provider appeals and grievances involving clinical information
• Ensure proper classification and processing of appeals and grievances within regulatory time frames
• Collaborate with other departments to thoroughly investigate issues related to treatment denial and quality of care

Required Qualifications

• Experience in handling appeals and grievances in a clinical setting
• Knowledge of NYS and federal regulations related to appeals and grievances
• Proficiency in data entry into medical management systems
• Ability to prepare for and participate in regulatory site visits
• Relevant education or training in healthcare or a related field