Manager, Clinical Appeals & Grievances

Healthfirst

. Prepare and plan weekend staff assignments and volume to ensure compliance .

Posted 9/21/2026full-timeRemote • United StatesMid-LevelSenior💰 $88,700 - $131,920 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing appeals and grievances within a healthcare environment, ensuring compliance with regulatory guidelines while optimizing processes and maintaining effective communication across departments. Proficient in utilizing care management systems and Microsoft Office tools to enhance operational efficiency.

Highest-signal resume keywords

Appeals And Grievances ManagementRegulatory ComplianceUtilization Review GuidelinesMicrosoft Word And ExcelClinical Practice Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Appeals ManagementGrievances ManagementClaims ProcessingUtilization ReviewCase ManagementRegulatory ComplianceData AnalysisProcess OptimizationLetter ReviewInventory Management

Soft Skills

Verbal CommunicationWritten CommunicationProblem SolvingCollaborationFeedback Provision

Tools & Technologies

Microsoft WordMicrosoft ExcelMacessCCMSTruCareHyland

Certifications & Qualifications

RNLPN

Industry Keywords

Healthcare ComplianceNYS ART 4449 PHLInterQualMillimanMedicare GuidelinesHIPAA

About the role

Key responsibilities & impact

Prepare and plan weekend staff assignments and volume to ensure compliance
Triage and assign expedited appeals
Standardize and optimize Appeals and Grievances routing
Manage weekend appeal inventory to ensure regulatory compliance
Communicate and escalate cases to Medical Peer reviewers
Maintain delegated vendor relationships and monitor vendor performance and compliance
Coordinate with outside departments on escalations, clarifications and appeal resolution
Manage letter review and printing and coordinate expedited printing with the mailroom
Review case change requests and cancellations and route follow-up appropriately
Review and submit Level 2 appeals packets to the appropriate entity
Maintain knowledge of industry trends, best practices and protocols
Identify trends and recommend improvement solutions
Deploy approaches to meet production, compliance and quality targets
Build partnerships across and outside operations
Provide feedback and recommendations to leadership on staff performance
Maintain confidentiality of member, provider, medical and departmental information
Perform additional duties as assigned

Requirements

What you’ll need

H.S. Diploma or GED
Proven work experience with appeals and grievances or a healthcare environment
Work experience demonstrating verbal and written communication skills
Experience working independently in a fast-paced environment that requires handling multiple priorities simultaneously
Willing and able to work a weekend schedule (Fri-Mon or Thurs-Sun)
Experience using Microsoft Word and Excel, corporate email and virtual filing systems such as Macess
Experience with care management systems such as CCMS, TruCare and Hyland
Bachelor’s degree preferred
RN or LPN strongly preferred
Experience in clinical practice with experience in appeals and grievances, claims processing, utilization review or utilization management/case management preferred
Understanding of Utilization Review Guidelines, including NYS ART 44 and 49 PHL, InterQual, Milliman or Medicare local coverage guidelines preferred
Must comply with HIPAA, state and federal compliance, and regulatory guidelines

Benefits

Comp & perks

Medical, dental and vision coverage (subject to eligibility requirements)
Incentive and recognition programs
Life insurance (subject to eligibility requirements)
401k contributions (subject to eligibility requirements)
Competitive compensation and benefits package