Clinical Specialist

Healthfirst, Inc.

Job Overview

Location

Remote - NY

Job Type

Full-time

Full Job Description

📋 Description

• The Clinical Specialist in Appeals & Grievances plays a critical role in safeguarding member rights and ensuring compliance with state and federal healthcare regulations by investigating and resolving clinical appeals and grievances related to service denials, payment issues, and quality of care concerns.
• This role directly impacts member satisfaction and regulatory adherence by serving as the frontline clinical reviewer who ensures fair, timely, and evidence-based resolution of disputes between Healthfirst, its members, and providers.
• Day-to-day responsibilities include receiving and triaging incoming appeals and grievances from members and providers, classifying each case by type (e.g., denial of service, denial of payment, or quality-of-care grievance), and initiating investigations in alignment with NYS and federal regulatory timelines—including standard and expedited (3-day) processing requirements.
• The specialist conducts thorough clinical reviews by accessing and interpreting medical records, treatment plans, and provider documentation to determine whether services were medically necessary, appropriately delivered, and in accordance with Healthfirst’s clinical policies and benefit structures.
• They collaborate closely with Medical Management, Utilization Review, Provider Relations, and Legal/Compliance teams to gather necessary information, clarify clinical discrepancies, and ensure holistic case resolution that addresses both administrative and clinical dimensions of each appeal or grievance.
• All case details, findings, and resolutions are accurately documented in Healthfirst’s medical management systems, ensuring audit readiness, regulatory compliance, and data integrity for reporting and quality improvement initiatives.
• The Clinical Specialist prepares for and participates in internal audits and external regulatory site visits by maintaining organized case files, generating summary reports, and demonstrating adherence to procedural and clinical standards set by NYS DFS, CMS, and other oversight bodies.
• They contribute to continuous improvement efforts by identifying trends in appeal and grievance data, participating in root cause analyses, and recommending policy or process enhancements to reduce recurrence of similar issues.
• The role requires strict adherence to internal policies, including confidentiality protocols (HIPAA), ethical decision-making, and unbiased clinical judgment, with additional duties assigned as needed to support departmental goals.
• Working within a mission-driven, nonprofit health plan, the Clinical Specialist gains deep expertise in healthcare regulatory frameworks, clinical utilization management, and member advocacy—skills that are highly transferable across clinical operations, compliance, and healthcare consulting roles.
• This position offers significant professional growth through exposure to complex clinical cases, interdisciplinary collaboration, and direct impact on healthcare equity and access, enabling the individual to develop leadership potential in clinical operations, quality improvement, or healthcare policy within a respected nonprofit organization.

🎯 Requirements

• Active, unrestricted RN license in New York State (or eligibility for licensure) with a minimum of 2 years of clinical experience in acute care, managed care, or utilization review settings.
• Demonstrated ability to interpret clinical documentation, apply medical necessity criteria (e.g., InterQual, MCG), and make evidence-based decisions regarding service denials, approvals, and quality of care concerns.
• Proven experience processing healthcare appeals and grievances within regulated timeframes, including familiarity with NYS Department of Financial Services (DFS) and federal CMS regulations governing timelines and documentation.
• Proficiency in using electronic health record (EHR) systems, medical management platforms (e.g., QNXT, Facets, or similar), and Microsoft Office Suite for case documentation, reporting, and data tracking.
• Strong written and verbal communication skills, with the ability to clearly articulate clinical rationale to non-clinical stakeholders, including members, providers, and regulatory auditors.
• Ability to work independently and collaboratively in a remote environment, manage multiple concurrent cases with attention to detail, and maintain composure under pressure when handling sensitive or high-stakes cases.

🏖️ Benefits

• Comprehensive medical, dental, and vision coverage with multiple plan options to suit individual and family needs, including wellness programs and preventive care incentives.
• Employer-matched 401(k) retirement plan with immediate eligibility and vesting, supporting long-term financial security and retirement planning.
• Generous paid time off (PTO) policy, including vacation, sick leave, and company-observed holidays, plus additional leave options for parental, bereavement, and jury duty needs.
• Life insurance, short- and long-term disability coverage, and employee assistance program (EAP) access at no cost to the employee.
• Professional development opportunities, including tuition reimbursement, licensure support, and access to internal training programs in clinical compliance, leadership, and healthcare innovation.
• Remote work flexibility with stipend for home office setup, enabling work-life balance while serving members across New York State.

Skills & Technologies

Remote

$83k-120k

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Healthfirst, Inc.

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About Healthfirst, Inc.

Healthfirst is a New York-based health insurance provider offering affordable, comprehensive plans to individuals, families, and seniors. For over 30 years, the company has delivered diverse options, including Essential Plans, Medicaid Managed Care, Child Health Plus, Marketplace plans, and specialized Medicare Advantage and Long-Term Care solutions. Healthfirst offers benefits like medical, prescription drug, dental, and vision coverage. Notably, Healthfirst maintains the only 5-star rated Essential Plan in New York for two consecutive years, solidifying its position as a trusted leader in accessible community healthcare.

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