Appeals & Grievances Clinical Coordinator

Healthfirst

. Support the clinical team to ensure timely and accurate processing of cases .

Posted 11/11/2026full-timeRemote • New York • United StatesMid-LevelSenior💰 $42,200 - $62,400 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates proficiency in case processing, documentation management, and regulatory compliance within the healthcare sector. Capable of collaborating effectively with clinical teams and external organizations while maintaining confidentiality and integrity of case files.

Highest-signal resume keywords

Knowledge Of NY State And Federal RegulationsProficiency In Microsoft OfficeClaims Payment Process KnowledgeData Entry In True Care SystemAbility To Work Independently And As A Team Member

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ProcessingDocumentation ManagementAppeal ResearchData EntryEvidence PreparationRegulatory ComplianceClaims Data System KnowledgeOrganizational Determination ResearchFile Integrity MaintenanceDeadline Management

Soft Skills

FlexibilityTeam CollaborationDeadline Focused

Tools & Technologies

True Care SystemMicrosoft Office

Certifications & Qualifications

HS DiplomaGED

Industry Keywords

New York State ART 44 PHLFederal Regulatory EnvironmentAppeals ProcessingGrievances ManagementClinical Review

About the role

Key responsibilities & impact

Support the clinical team to ensure timely and accurate processing of cases
Set up case files for clinical review
Conduct appeal research and filing, including organizational determination research
Request member medical records and organize documentation
Prepare written summaries and schedule cases
Process case reviews and document appeal resolutions
Send complete case files to external review organizations as required by regulatory guidelines
Prepare cases by gathering documentation, loading evidence, and making calls to members and providers
Generate and print determination and authorization notification letters
Complete data entry and authorization creation in the True care system
Notify the team lead of appeal patterns, claim errors, configuration issues, and systemic problems
Liaise with providers and members during appeal processing
Collaborate with Contact Center Operations, Claims, DSE, and E&B
Ensure appeals and grievances are processed within New York State and federal timeframes
Prepare evidence packages and draft letters
Request denial files from delegated vendors and prepare cases for Clinical Specialist reviews
Maintain file integrity, content, and confidentiality
Participate in meetings and perform additional duties as assigned

Requirements

What you’ll need

HS Diploma or GED
Knowledge of related NY state and federal regulations highly desirable
Proficiency in Microsoft Office required
Knowledge of the New York state ART 44 PHL and federal regulatory environment
Knowledge of claims payment process and claims data system (MHS)
Ability to work both independently and as a team member
Demonstrated ability to be deadline focused and flexible in order to adjust to priority changes

Benefits

Comp & perks

Medical, dental and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package