NY Licensed Clinical Specialist

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist responsible for managing member complaints and clinical case resolutions.

Key Responsibilities

• Develop and resolve clinical cases, ensuring compliance with regulations and internal policies
• Prepare cases for Medical Director Review and external appeals processes
• Manage a caseload while meeting regulatory timeframes and productivity expectations

Required Qualifications

• Registered Nurse (RN), Licensed Practical Nurse (LPN), or Dental Hygienist
• Bachelor's degree preferred
• Experience in clinical practice, appeals & grievances, or utilization management
• Understanding of Utilization Review Guidelines and related standards
• Ability to manage large caseloads in a fast-paced environment