NY Licensed Appeals Specialist

Key responsibilities: Develop and resolve clinical cases related to pre-existing conditions, prior approvals, and medical necessity while adhering to regulatory timeframes Prepare cases for Medical Director Review and external appeal processes, ensuring all pertinent information is accurately documented Collaborate with internal and external stakeholders to effectively manage a caseload and communicate case updates

Required qualifications: Current RN, LPN, or Dental Hygienist license Experience in clinical practice with a focus on appeals & grievances, claims processing, or utilization management Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL Proficiency in Microsoft Word and Excel, as well as experience with care management systems Ability to manage large caseloads in a fast-paced environment