Appeals and Grievances Clinical Specialist

📋 Description

• • The Appeals and Grievances Clinical Specialist serves as a subject matter expert responsible for clinical case development and resolution, ensuring compliance with federal and state regulations while managing a caseload of member and provider complaints regarding clinical and non-clinical services.
• • Day-to-day responsibilities include researching clinical issues, interpreting regulations, referencing Healthfirst’s internal policies, resolving cases, updating documentation, preparing cases for Medical Director Review and external appeals (including Maximus Federal Services and Fair Hearings), and communicating effectively with colleagues to ensure timely handoffs and adherence to productivity and quality metrics.
• • The Appeals & Grievances unit at Healthfirst collaborates across internal and external divisions to resolve member and provider complaints in a timely and compliant manner, supporting the organization’s mission to ensure appropriate access to care through rigorous case management.
• • In this role, the specialist will develop expertise in clinical appeals processes, gain deep familiarity with utilization review guidelines (such as InterQual and Milliman), strengthen decision-making and regulatory compliance skills, and contribute to high-stakes case resolutions that impact member care and provider relationships.