Appeals and Grievances Clinical Specialist

Duties and Responsibilities:

+ Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end to end process requires the Specialist to independently:
+ Research issues
+ Reference and understand HFs internal health plans policies and procedures to frame decisions
+ Interpret regulations
+ Resolve cases and make critical decisions
+ Update file documentation such as the file notes and case summary
+ Manage all duties within regulatory timeframes
+ Communicate effectively to hand-off and pick-up work from colleagues
+ Work within a framework that measures productivity and quality for each Specialist against expectations

+ Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diag...