Appeals and Grievances Clinical Specialist Job at Healthfirst (New York City)

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Maces)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Appeals and Grievances Clinical Specialist

The Appeals & Grievances (A&G) unit manages Healthfirst member complaints, griev...

Location

United States , New York City; Lake Mary

Salary:

73400.00 - 120360.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

RN, LPN OR Dental Hygienist
Bachelor’s degree
Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management
Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
Ability to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess)
Experience with care management systems, such as CCMS, TruCare and Hyland
Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Job Responsibility

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services
Research issues
Reference and understand HF’s internal health plans policies and procedures to frame decisions
Interpret regulations
Resolve cases and make critical decisions
Update file documentation such as the file notes and case summary
Manage all duties within regulatory timeframes
Communicate effectively to hand-off and pick-up work from colleagues
Work within a framework that measures productivity and quality for each Specialist against expectations
Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Pharmacy Technician

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Keaau

Salary:

18.00 - 28.00 USD / Hour

CVS Health

Expiration Date

July 14, 2026

Requirements

Must comply with any state board of pharmacy requirements or laws governing the practice of pharmacy, which includes but is not limited to, age, education, and licensure/certification
If the state board of pharmacy does not address or mandate a minimum age requirement, must be at least 16 years of age
If the state board of pharmacy does not address or mandate a minimum educational requirement, must have a high school diploma or equivalent, or be actively enrolled in high school or high school equivalency program
State-level licensure and national certification requirements vary by state

Job Responsibility

Living our purpose by following all company SOPs at each workstation to help our Pharmacists manage and improve patient health
Following pharmacy workflow procedures at each pharmacy workstation (i.e., production, pick-up, drive-thru, and drop-off) for safe and accurate prescription fulfillment
Contributing to positive patient experiences by showing empathy and genuine care: creating heartfelt and personalized moments while serving patients at pick-up, drive-thru, and over the phone
keeping patients healthy by offering immunizations and other services at the register and over the phone
and demonstrating compassionate care by solving or escalating patient problems
Completing basic inventory activities, as permitted by law, and as directed by the pharmacy leadership team, such as accurately putting away medication deliveries and completing cycle counts, returns-to-stocks, waiting bin inventories, etc.
Contributing to a high-performing team, embracing a growth mindset, and being receptive to feedback
actively seeking opportunities to expand clinical and technical knowledge needed to better assist patients
Remaining flexible for both scheduling and business needs, while contributing to a safe, inclusive, and engaging team dynamic
voluntarily traveling to stores in the market to work shifts as needed by the business

What we offer

dental
vision
wellness resources
employee discounts
access to certain voluntary benefits
other programs

Parttime

District Support Pharmacist

We're building a world of health around every individual — shaping a more connec...

Location

United States , Chicago

Salary:

60.00 - 76.00 USD / Hour

CVS Health

Expiration Date

Until further notice

Requirements

Active Pharmacist License in the state where the Store is located
Active National Provider Identifier (NPI)
Not on the DEA Excluded Parties list

Job Responsibility

Living our purpose by helping to manage and improve patient health through safe and appropriate dispensing, counseling, and immunizing practices
Traveling the district to fill pharmacist shifts as scheduled by the District Performance Coordinator (DPC)
overseeing the pharmacy and serving as the Pharmacy Manager's proxy during bench shifts without overlap
Supporting safe and accurate prescription fulfillment by following—and directing the pharmacy team to follow—pharmacy workflow procedures and utilizing the safety guardrails at every workstation
Assumes Pharmacy Manager's day-to-day duties when serving as the only or the primary pharmacist-on-duty
Contributing to positive patient experiences by showing empathy and genuine care and coaching the pharmacy team to do the same: demonstrating compassionate care, collaborating with the patient's total healthcare team, and proactively resolving insurance and/or medication issues
Proactively offering and delivering immunizations to keep patients healthy
engaging and supporting Pharmacy Technicians to learn to immunize
Supporting the effective management of pharmacy inventory in all pharmacies worked by following—and guiding the pharmacy team to follow—all inventory best practices, with a special focus on protecting cold chain products for our patients and our business
Remaining flexible for both scheduling and business needs, while contributing to a safe, inclusive, and engaging team dynamic

What we offer

dental
vision
wellness resources
employee discounts
access to certain voluntary benefits

Parttime

Finance Manager

Swale Academies Trust is seeking to appoint a Finance Manager to join our centra...

Location

United Kingdom , Sittingbourne

Salary:

44235.00 - 50199.00 GBP / Year

Swale Academies Trust

Expiration Date

June 30, 2026

Requirements

Hardworking, friendly and organised individual
ideally with school finance experience
strong people management skills
strong team player with excellent interpersonal skills
able to prioritise both their own workload and that of others
good working knowledge of IRIS Financials (PSF) and Access Budgeting will be a distinct advantage
experience in producing management accounts
proactive budget monitoring
setting realistic three and five year budgets utilising ICFP tools (ASOT)
supportive & effective line management

Job Responsibility

Production of meaningful monthly management accounts
proactive budget monitoring through the year
setting realistic three and five year budgets utilising ICFP tools (ASOT)
supportive & effective line management

What we offer

Local Government Pension Scheme with a generous employer contribution
Enhanced Maternity Pay
Salary Sacrifice Shared Cost AVC (Additional Voluntary Contribution) Scheme
Employee Referral Recruitment Incentive
Access to training and development
On-site Parking
Discounts with local and national retailers, cinemas and restaurants
Employee Assistance Programme – Wellbeing and advice
Cycle to Work scheme

Fulltime

Grc Specialist Senior

The GRC Specialist Senior is responsible for conducting security assessments, co...

Location

United States , Coral Gables

Salary:

Not provided

City National Bank of WV

Expiration Date

Until further notice

Requirements

5-7 years of of applied work experience in cyber security compliance management, cyber security programs, data engineering, analytics or integration, audits, assessments, risk and remediation
Knowledge of AI concepts (LLMs, prompt design, limitations, hallucinations, etc.)
Knowledge of information security management, governance, and compliance principles, practices, laws, rules, regulations, and frameworks such as GLBA, FFIEC, and NIST
Knowledge of IT systems and processes, network infrastructure, data architecture, and protocols
Skill in applying cyber and cloud security frameworks, architecture, design, operations, controls, and service orchestration
Proficiency in Microsoft Office products (Word, Excel, PowerPoint)
Ability to develop and implement enterprise governance, risk, and compliance strategies and solutions
Ability to research and locate information related to internal and external organizations using online and other sources
Skill in security project management and planning
Ability to maintain confidentiality and handle sensitive information appropriately

Job Responsibility

Coordinate risk and control self-assessments with IT and cybersecurity subject matter experts and enterprise risk management team
Conduct control testing and document results to identify potential gaps in control design and/or control operating effectiveness
Collaborate with GRC, engineering, SecOps, IT operations, and BCP teams to define requirements and ensure scalable, secure, and maintainable AI-driven automation solutions
Identify opportunities to develop automated solutions using Microsoft Copilot, Power Automate, or another approved automation tool
Develop and maintain cybersecurity and IT policies, standards, procedures, program metrics and help develop automated compliance reports and risk metrics for executive leadership, to improve decision-making and reduce operational risk
Coordinate work assignments with process owners, control owners, external auditors, and consultants, ensuring issues are documented, monitored, and resolved
Advise internal stakeholders on internal control design for ongoing risk mitigation of information systems based on regulatory requirements and best practices
Communicate security issues and risks effectively to diverse audiences and ensure compliance with applicable controls based on a unified framework
Identify and correct process gaps proactively, recommending improvements to advance the Bank’s information security program maturity in alignment with company goals
Guide program leaders on risk remediation efforts, ensuring adequacy of response and timeliness based on risk severity

What we offer

Medical, dental, and vision plans with employer contributions
401(k) with matching
Generous PTO and paid holidays
Access to mental health and financial wellness resources
Tuition Reimbursement
Flex Time

Fulltime