New York Licensed Clinical Specialist

Job Summary

New York Licensed Clinical Specialist, this full-time position is responsible for managing clinical case development and resolution related to member complaints and appeals while ensuring compliance with regulations.

Key Responsibilities

• Manage case development and resolution for clinical cases, ensuring compliance with regulatory timeframes
• Prepare cases for Medical Director Review and external appeals, ensuring all pertinent information is gathered
• Handle clinical claim appeals from both participating and non-participating providers as needed

Required Qualifications

• Registered Nurse (RN) license
• Bachelor's degree preferred
• Experience in clinical practice, appeals & grievances, or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Able to manage large caseloads and work effectively in a fast-paced environment