About this role

Managing clinical case development and resolution, the full-time Remote New York Licensed Clinical Specialist will handle member complaints and appeals, ensuring compliance with regulations while collaborating across divisions. Key responsibilities Oversee case development and resolution for clinical cases, including medical necessity and prior approval, while managing documentation and regulatory timeframes Prepare cases for Medical Director Review and external appeals, ensuring all necessary information is gathered and presented effectively Communicate with colleagues to facilitate case hand-offs and maintain productivity and quality standards Required qualifications Current RN license Bachelor's degree preferred Experience in clinical practice related to appeals & grievances, claims processing, or utilization management Understanding of Utilization Review Guidelines and related regulations Proficiency in various computer applications and care management systems

Source listing: virtualvocations_main