NY State Licensed Clinical Specialist

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist.

Key Responsibilities

• Manage case development and resolution of clinical cases, ensuring compliance with regulations
• Prepare cases for Medical Director Review and external appeals, ensuring all relevant information is included
• Handle Department of Health and executive complaints as needed

Required Qualifications

• RN or LPN license required
• Bachelor's degree preferred
• Experience in clinical practice with a focus on appeals & grievances or utilization management
• Knowledge of Utilization Review Guidelines and care management systems
• Ability to manage large caseloads in a fast-paced environment