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

Medical Appeals/Grievance Specialist II - Registered Nurse

Responsible for utilizing clinical acumen and managed care expertise related to ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

1 year experience in clinical and health insurance or other healthcare related field
3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW.
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
Maintain confidentiality and privacy
Advanced clinical knowledge

Job Responsibility

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Maintain complete and accurate records per department policy.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
Demonstrate ability to apply plan policies and procedures effectively.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and current developments in the fields of medicine and managed care.

Fulltime

New

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

New

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, and 401k contributions

Fulltime

New

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

New

Pharmacy Technician

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

Location

United States , Lake Worth

Salary:

16.50 - 25.00 USD / Hour

CVS Health

Expiration Date

April 09, 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
Regular and predictable attendance, including nights and weekends
Ability to complete required training within designated timeframe
Attention and Focus: Ability to concentrate on a task over a period of time
Ability to pivot quickly from one task to another to meet patient and business needs
Ability to confirm prescription information and label accuracy, ensuring patient safety
Customer Service and Team Orientation: Actively look for ways to help people, and do so in a friendly manner
Notice and understand patients’ reactions, and respond appropriately

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

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Parttime

New

District Support Pharmacist

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

Location

United States , Glastonbury

Salary:

60.00 - 76.00 USD / Hour

CVS Health

Expiration Date

April 09, 2026

Requirements

Active Pharmacist License in the state where the Store is located
Active National Provider Identifier (NPI)
Not on the DEA Excluded Parties list
Ability to travel within a reasonable radius to support market staffing as business needs require
Regular and predictable attendance, including nights and weekends
Ability to complete required training within designated timeframe
Attention and Focus: Ability to concentrate on a task over a period of time
Ability to pivot quickly from one task to another to meet patient and business needs
Ability to confirm prescription information and label accuracy, ensuring patient safety
Customer Service and Team Orientation: Actively look for ways to help people, and do so in a friendly manner

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

Affordable medical plan options
a 401(k) plan (including matching company contributions)
an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
paid time off
flexible work schedules
family leave
dependent care resources
colleague assistance programs
tuition assistance

Parttime

New

Pharmacy technician

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

Location

United States , Canfield

Salary:

17.00 USD / Hour

CVS Health

Expiration Date

April 06, 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
Regular and predictable attendance, including nights and weekends
Ability to complete required training within designated timeframe
Attention and Focus: Ability to concentrate on a task over a period of time
Ability to pivot quickly from one task to another to meet patient and business needs
Ability to confirm prescription information and label accuracy, ensuring patient safety
Customer Service and Team Orientation: Actively look for ways to help people, and do so in a friendly manner
Notice and understand patients’ reactions, and respond appropriately

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

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility

Parttime

New

Staff Pharmacist

At CVS Health, we’re building a world of health around every consumer and surrou...

Location

United States , Canyon Country

Salary:

60.00 - 81.00 USD / Hour

CVS Health

Expiration Date

March 15, 2026

Requirements

Active Pharmacist License in the state where the Store is located
Active National Provider Identifier (NPI)
Not on the DEA Excluded Parties list
Regular and predictable attendance, including nights and weekends
Ability to complete required training within designated timeframe
Ability to concentrate on a task over a period of time
Ability to pivot quickly from one task to another to meet patient and business needs
Ability to confirm prescription information and label accuracy, ensuring patient safety
Actively look for ways to help people, and do so in a friendly manner
Notice and understand patients’ reactions, and respond appropriately

Job Responsibility

Living our purpose by helping to manage and improve patient health through safe and appropriate dispensing, counseling, and immunizing practices
Taking direction from the Pharmacy Manager and overseeing the pharmacy as their proxy during bench shifts without overlap, including strengthening pharmacy performance measures through effective coaching and consistent follow-up of pharmacy team members and providing feedback about pharmacy team performance to the Pharmacy Manager as needed
Assumes Pharmacy Manager’s day-to-day duties when serving as the only or the primary pharmacist-on-duty
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
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 by following—and coaching the pharmacy team to follow—all inventory best practices, with a special focus on protecting cold chain products for our patients and our business
Partnering with the Pharmacy Manager to ensure pharmacy operations are compliant with the appropriate state Board of Pharmacy regulations at all times
escalating issues or concerns to the Pharmacy Manager and/or Rx DL for timely resolution if/as needed

What we offer

Affordable medical plan options
401(k) plan (including matching company contributions)
employee stock purchase plan
wellness screenings
tobacco cessation and weight management programs
confidential counseling
financial coaching
paid time off
flexible work schedules
family leave

Fulltime

Appeals and Grievances Clinical Specialist

Healthfirst

Location:
United States , New York City ▼
Lake Mary

Category:
Health and Beauty

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Additional Information:

Job Posted:
February 21, 2026

Looking for more opportunities? Search for other job offers that match your skills and interests.

Similar Jobs for Appeals and Grievances Clinical Specialist

Medical Appeals/Grievance Specialist II - Registered Nurse

Appeals and Grievances Clinical Specialist

Appeals and Grievances Clinical Specialist