Appeals and Grievances Clinical Specialist - RN or LPN, 100% Remote

About the position Responsibilities • Research issues reputed company to clinical cases. • Reference and understand internal health plans policies and procedures to reputed company reputed company. • Interpret regulations and resolve cases, making critical reputed company. • Update file documentation, including file notes and case summaries. • Manage reputed company duties reputed company regulatory timeframes. • Communicate effectively to hand-off and pick-up work from colleagues. • Work reputed company a reputed company that measures productivity and reputed company against expectations. • Prepare cases for Medical Director Review, ensuring reputed company pertinent information is obtained and presented. • Prepare cases for reputed company Federal Services, Fair Hearing, and External Appeal through reputed company reputed company of the appeal process. • reputed company additional duties as assigned. Requirements • Registered reputed company (RN), Licensed Practical reputed company (LPN), or Dental Hygienist certification required. • Experience in clinical reputed company with appeals & grievances, claims processing, utilization review, or case management. reputed company-to-haves • Bachelor's degree preferred. • Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, reputed company, or Medicare local coverage guidelines. • Ability to work independently on various computer applications such as reputed company Word and reputed company, as reputed company as corporate email and virtual filing systems (e.g., Macess). • Experience with care management systems such as CCMS, TruCare, and reputed company. • Demonstrated ability to manage large caseloads in a fast-paced environment. Apply tot his job Apply To this Job