To support the management of clinical appeals and grievances, the full-time Appeals & Grievances Clinical Specialist will receive, investigate, and respond to member and provider issues while working remotely across various states. Key responsibilities Ensures proper classification and processing of appeals and grievances according to company policy Enters data into medical management services and collaborates with other departments for thorough investigations Prepares for and participates in regulatory site visits and performs additional assigned duties Required qualifications LPN or RN license Experience in clinical practice with a focus on appeals & grievances or utilization management Understanding of Utilization Review Guidelines, InterQual, or Medicare Guidelines Proficiency in Microsoft Word, Excel, and corporate email systems Ability to manage large caseloads in a fast-paced environment
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