New York Licensed Clinical Specialist

Job Summary

Managing clinical case development and resolution, the full-time Remote New York Licensed Clinical Specialist will handle member complaints and appeals, ensuring compliance with regulations while collaborating across divisions.

Key responsibilities

• Oversee case development and resolution for clinical cases, including medical necessity and prior approval, while managing documentation and regulatory timeframes
• Prepare cases for Medical Director Review and external appeals, ensuring all necessary information is gathered and presented effectively
• Communicate with colleagues to facilitate case hand-offs and maintain productivity and quality standards

Required qualifications

• Current RN license
• Bachelor's degree preferred
• Experience in clinical practice related to appeals & grievances, claims processing, or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Proficiency in various computer applications and care management systems