Remote Appeals Clinical Specialist

Job Summary

A company is looking for an Appeals and Grievances Clinical Specialist - RN, LPN or Dental Hygienist - 100% Remote.

Key Responsibilities

• Manage clinical case development and resolution for member complaints and appeals
• Prepare cases for Medical Director Review and external appeals, ensuring all necessary information is compiled
• Handle Department of Health and executive complaints as required

Required Qualifications

• Valid RN, LPN, or Dental Hygienist license
• Bachelor's degree preferred
• Experience in clinical practice, appeals & grievances, or utilization management
• Familiarity with Utilization Review Guidelines and care management systems
• Ability to manage large caseloads in a fast-paced environment