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Healthfirst A&G Clinical Specialist - RN or LPN, 100% Remote in Home Office, Massachusetts

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

The A&G Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle clinical claim appeals that come from Healthfirst participating and non-participating providers.

This position is 100% remote, working from home.

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 HF’s 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, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

  • Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process

  • Additional duties as assigned

Minimum Qualifications:

  • RN or LPN

Preferred Qualifications:

  • Bachelor’s degree

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

  • Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Milliman or Medicare local coverage 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). Experience with care management systems, such as CCMS, TruCare and Hyland.

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

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to an environment where our employees are fully vaccinated against COVID-19. As a prospective new team member, you must be fully vaccinated with a CDC/FDA approved COVID-19 shot(s) to work in our offices. If you are selected to interview for this role, we will explain our vaccination policy in further detail and ensure you are comfortable moving forward with this company policy.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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.

EEO Law Poster and Supplement (

All hiring and recruitment at Healthfirst is transacted with a valid “” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.