A&G Clinical Specialist

This is a fully remote position, open to applicants in Maine, +9 more states.

📋 Description

• Oversee the development and resolution of clinical cases related to Appeals & Grievances.

• Ensure adherence to Federal and/or State regulations.

• Conduct independent investigations and resolve cases initiated by members or providers.

• Address complaints from the Department of Health and executive level as required.

• Manage clinical claim appeals from both participating and non-participating providers.

• Investigate issues and consult internal health plan policies and procedures.

• Interpret regulations and make essential decisions on cases.

• Maintain and update file documentation, including notes and case summaries.

• Perform tasks within regulatory deadlines.

• Communicate efficiently to transfer work between colleagues.

• Meet productivity and quality standards.

• Prepare cases for Medical Director Review with comprehensive investigative details.

• Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal throughout all appeal levels.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• RN or LPN certification.

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

• Proven knowledge of Utilization Review Guidelines (NYS ART 44 and 49 PHL), Milliman, or Medicare local coverage guidelines.

• Proficient in working independently with Microsoft Word and Excel, corporate email, and virtual filing systems like Macess.

• Familiarity with care management systems such as CCMS, TruCare, and Hyland.

• Demonstrated capability to manage extensive caseloads and function effectively in a dynamic environment.

• Ability to work a schedule of Wednesday-Saturday, Thursday-Sunday, Friday-Monday, Sunday-Wednesday, Tuesday-Saturday, Wednesday-Sunday, or Sunday-Thursday based on the chosen shift.

• Eligibility to work remotely from one of the approved locations.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Incentive and recognition programs.

• Life insurance.

• 401k contributions.

• Competitive compensation and benefits package.