NY State Licensed Clinical Specialist

Job Summary

To ensure compliance with Federal and State regulations, the full-time salaried NY State Licensed Clinical Specialist will manage clinical case development and resolution for member complaints and appeals, working remotely or onsite as needed.

Key responsibilities

• Manage case development and resolution for clinical cases, ensuring timely and compliant handling of member or provider complaints
• Prepare cases for Medical Director Review and external appeals, gathering and presenting all necessary information
• Investigate and resolve issues independently while maintaining accurate documentation and adhering to regulatory timeframes

Required qualifications

• Current RN, LPN, or Dental Hygienist license
• Experience in clinical practice, particularly in appeals and grievances, claims processing, or utilization management
• Understanding of Utilization Review Guidelines and related regulations
• Proficiency in various computer applications, including Microsoft Word, Excel, and care management systems
• Ability to manage large caseloads in a fast-paced environment