NY Licensed Appeals Specialist

Job Summary

Managing clinical case development and resolution, the full-time NY Licensed Appeals Specialist will investigate and resolve member or provider complaints and appeals regarding clinical services while working remotely.

Key responsibilities

• Develop and resolve clinical cases related to pre-existing conditions, prior approvals, and medical necessity while adhering to regulatory timeframes
• Prepare cases for Medical Director Review and external appeal processes, ensuring all pertinent information is accurately documented
• Collaborate with internal and external stakeholders to effectively manage a caseload and communicate case updates

Required qualifications

• Current RN, LPN, or Dental Hygienist license
• Experience in clinical practice with a focus on appeals & grievances, claims processing, or utilization management
• Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL
• Proficiency in Microsoft Word and Excel, as well as experience with care management systems
• Ability to manage large caseloads in a fast-paced environment