NY State Licensed Clinical Specialist

Job Summary

To support the Appeals & Grievances unit, the full-time NY State Licensed Clinical Specialist will manage clinical case development and resolution, ensuring compliance with regulations while working remotely.

Key responsibilities

• Develop and resolve clinical cases related to member grievances and appeals, ensuring timely compliance with regulatory requirements
• Prepare cases for Medical Director Review and external appeals, gathering all necessary information during investigations
• Handle Department of Health and executive complaints, managing a caseload effectively within a fast-paced environment

Required qualifications

• Current RN license in New York State
• Bachelor's degree preferred
• Experience in clinical practice with a focus on appeals & grievances, claims processing, or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Proficiency in Microsoft Word, Excel, and care management systems