Healthfirst Clinical Specialist, Appeals & Grievances (RN or LPN; Telecommuter) in Home Office, New York


The Appeals & Grievances Clinical Specialist (RN or LPN) is responsible for receiving, investigating and responding verbally and in writing to member and provider clinical appeals and grievances.

Minimum Qualifications:

  • LPN or RN

Preferred Qualifications:

  • Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management.

  • Understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual or Medicare Guidelines.

  • Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system. (ie. Macess).

  • Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Duties and Responsibilities:

  • Ensures that appeals and grievances are properly classified (e.g. denial of service, denial of payment, or a grievance about a provider)

  • Processes appeals and grievances in accordance with internal company policy

  • Enters data into appropriate medical management services

  • Collaborates with other departments to thoroughly investigate appeal and grievances.

  • Prepares for and participates in regulatory site visits.

  • Additional duties as assigned.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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