New York Licensed Clinical Specialist

Job Summary

A company is looking for a Clinical Specialist responsible for managing clinical case development and resolution in compliance with regulations.

Key Responsibilities

• Manage case development and resolution for clinical cases including pre-existing conditions, prior approval, and medical necessity
• Prepare cases for Medical Director Review and external appeals while ensuring all pertinent information is collected
• Handle Department of Health and executive complaints as needed, and manage clinical claim appeals

Required Qualifications

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