New York Licensed Clinical Specialist

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



Key Responsibilities

Manage clinical case development and resolution, ensuring compliance with regulations
Prepare cases for Medical Director Review and external appeals processes
Handle Department of Health and executive complaints as needed


Required Qualifications

Active RN, LPN, or Dental Hygienist license
Bachelor's degree preferred
Experience in clinical practice, appeals & grievances, or utilization management
Understanding of Utilization Review Guidelines and related regulations
Ability to manage large caseloads in a fast-paced environment