NY State Licensed Clinical Specialist

To ensure compliance with Federal and State regulations, the full-time salaried NY State Licensed Clinical Specialist will manage clinical case development and resolution for member complaints and appeals, working remotely or onsite as needed. Key responsibilities Manage case development and resolution for clinical cases, ensuring timely and compliant handling of member or provider complaints Prepare cases for Medical Director Review and external appeals, gathering and presenting all necessary information Investigate and resolve issues independently while maintaining accurate documentation and adhering to regulatory timeframes Required qualifications Current RN, LPN, or Dental Hygienist license Experience in clinical practice, particularly in appeals and grievances, claims processing, or utilization management Understanding of Utilization Review Guidelines and related regulations Proficiency in various computer applications, including Microsoft Word, Excel, and care management systems Ability to manage large caseloads in a fast-paced environment