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HealthfirstCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical appeals and grievances management, including a strong understanding of Utilization Review Guidelines and the ability to manage large caseloads effectively within regulatory timeframes. Proficient in preparing comprehensive case documentation for reviews and appeals while ensuring compliance with federal and state regulations.
Highest-signal resume keywords
RN, LPN, Or Dental HygienistUtilization Review GuidelinesCase ManagementMicrosoft Word And ExcelCare Management Systems
About the role
Key responsibilities & impact- Develop and resolve clinical appeals and grievances, including cases involving pre-existing conditions, prior approval, medical necessity, pre-certification, continued stay, reduction, termination, and suspension of services
- Independently research issues and interpret regulations
- Apply internal health plan policies and procedures to frame decisions
- Resolve cases and make critical decisions
- Update file notes, case summaries, and other documentation
- Manage caseloads within regulatory timeframes
- Communicate with colleagues to hand off and pick up work
- Work within productivity and quality expectations
- Prepare cases for Medical Director Review with complete clinical, contractual, diagnostic, CPT, and response information
- Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all appeal levels
- Manage Department of Health and executive complaints as needed
- Handle clinical claim appeals from participating and non-participating providers as needed
- Attend A&G/Operations meetings and Town Halls, with occasional travel to company locations
Requirements
What you’ll need- RN, LPN, or Dental Hygienist required
- Bachelor’s degree preferred
- Experience in clinical practice with experience in appeals and grievances, claims processing, utilization review, utilization management, or case management
- Demonstrated understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL, InterQual, Milliman, or Medicare local coverage guidelines
- Ability to work independently with Microsoft Word, Microsoft Excel, corporate email, and virtual filing systems such as Macess
- Experience with care management systems such as CCMS, TruCare, and Hyland
- Demonstrated ability to manage large caseloads and work effectively in a fast-paced environment
- Ability to comply with applicable Federal and/or State regulations and regulatory timeframes
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
- Travel and expenses covered according to policy for required travel to divisional meetings and Town Halls
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Appeals ManagementClaims ProcessingUtilization ReviewCase Documentation PreparationRegulatory Compliance
Soft Skills
Independent ResearchEffective CommunicationTime Management
Tools & Technologies
MacessCCMSTruCareHyland
Certifications & Qualifications
RNLPNDental Hygienist
Industry Keywords
Pre-Existing ConditionsMedical NecessityPrior ApprovalDepartment Of HealthExternal Appeal