New York Licensed Clinical Specialist

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 appeal processes
• Handle Department of Health and executive complaints as needed

Required Qualifications

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