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 appeals processes
• Handle member and provider complaints, maintaining documentation and communication

Required Qualifications

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