Healthfirst Work from Home Jobs

By | November 24, 2022

Job Responsibilities : A&G Clinical Specialist – RN or LPN, 100% Remote

Salary : 95199 per Year

Company : HealthFirst

Location : Remote US

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:


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

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 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.

Hiring Range*:

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.

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