Job Responsibilities : A&G Clinical Specialist – RN or LPN, 100% Remote
Salary : 95199 per Year
Company : HealthFirst
Location : Remote US
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:
Reference and understand HF’s internal health plans policies and procedures to frame decisions
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
RN or LPN
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
Since we care so greatly about our employees’ and members’ wellbeing Healthfirst has implemented various COVID-related health and safety requirements for our workforce. Employees are expected to follow the Company’s current COVID-19 or other infectious disease health and safety protocols including local requirements which may include sharing information regarding your vaccine status and mask wearing. Protocols may change in the future with the evolving public health landscape. Healthfirst will consider accommodation requests as required by applicable law.
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 careers@Healthfirst.org 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 “@healthfirst.org” 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 @healthfirst.org 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.
Greater New York City Area (NY NJ CT residents): $79300 – $114400
All Other Locations (within approved locations): $69800 – $101920
As a candidate for this position your salary and related elements of compensation will be contingent upon your work experience education licenses and certifications and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary Healthfirst offers employees a full range of benefits such as medical dental and vision coverage incentive and recognition programs life insurance and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
- The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire or for a job promotion or transfer into this role.