Available Positions for Healthcare

Qualifications

The qualified candidate must be a RN licensed in NY and it would be a plus to have a NJ license. The candidate must have previous experience in Appeals and Grievances, Claims Processing or Utilization Management/Case management in a managed care organization or hospital setting. The right person will have the ability to identify clinical quality of care issue and differentiate between PCP rendered care and specialty care. It is important for the candidate to have knowledge of the New York State and Federal Regulatory environment.

Job Description

The Appeals and Grievances Clinical Specialist is responsible for supporting the Manager and Department Specialists regarding clinical issues. In addition, the Specialist is responsible for receiving, investigating and responding in writing to member and provider appeal and grievances involving review of clinical information. The Specialist will ensure appeals and grievances are categorized and processed within New York State and Federal timeframes and identify potential quality issues and initiate investigations. He/She will refer substantiated quality of care issues to the Quality Improvement and Credentialing Departments and maintain absolute file integrity with regards to content, location and confidentiality. The Specialist will prepare for and participate in regulatory site visits and develop and assist with training for new department employees. (11720)