• Grievance and Appeals Clinical Behavioral Health Specialist

    Job Locations US-RI-Smithfield
    Req No.
    Grievance And Appeals
    Regular Full-Time
  • Overview

    The Grievance and Appeals Clinical BH Specialist (Specialist) will be primarily responsible for performing a preliminary review and preparing BH-related clinical appeals for physician review for Neighborhood’s Medicare-Medicaid Population (MMP). The Specialist will also be responsible for handling BH-related informal complaints and formal grievances for Neighborhood’s Exchange and Medicaid Lines of Business. The Specialist will handle, review, and ensure compliance with all BH-related appeal and complaint/grievance activities. The Specialist will handle these appeals and complaints/grievances in accordance with Neighborhood Policies & Procedures in an efficient and timely manner within required timeframes and in accordance with CMS, EOHHS, NCQA, and other applicable regulatory requirements. The Specialist will perform appeal reviews using medical and/or behavioral health records in conjunction with established clinical guidelines and member benefit plans. The Specialist will communicate the outcome of the appeals or complaint/grievance process with Neighborhood members, a member’s authorized representative, and/or provider, as well as any internal and external partners, as needed/required.


    • Utilizes designated clinical criteria along with clinical BH knowledge to make timely and compliant appeal decisions.
    • Timely and compliant BH-related complaint/grievance resolution for all Neighborhood lines of business in accordance with Neighborhood Policies & Procedures.
    • Assists the Neighborhood BH Medical Director with appeal determinations related to Behavioral Health Services which have been previously denied by Neighborhood’s BH Vendor for our Medicare-Medicaid Population (MMP).
    • Collects information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation as necessary to reach prospective, concurrent and retrospective decisions in the appeals process.
    • Reviews and interprets a variety of instructions and medical notes furnished in written and oral form to determine appropriate appeal outcome while also applying regulatory requirements and accreditation standards to all appeal and complaint review activity.
    • Applies accepted criteria to review the BH Vendor’s Organization Determination process, utilizes the parameters and inputs review data into systems.
    • Prepares and submits projects, reports or assignments as needed to meet department initiatives and/or objectives.
    • Produces approval and/or denial letters on behalf of the Medical Director for submission to Neighborhood members, a member’s authorized representative, and/or provider, as well as any internal and external partners, as needed/required.
    • Ensures quality member-focused approach and excellent customer service, as well as maintenance of confidentiality, and assistance in identifying process improvement opportunities related to appeals and complaint/grievance processing.
    • Ensures accurate data entry into the appeals management system, including but not limited to appropriate procedure and diagnosis codes, approved abbreviations and relevant clinical information documented per departmental policies.
    • Performs special duties as assigned.



    • Registered Nurse with two (2) years of experience in a Behavioral Health clinical setting with general nursing exposure in Utilization Management to include pre-authorization, utilization review, concurrent review, discharge planning, Case Management w/review, and/or skilled nursing facility reviews.
    • Minimum two (2) years of experience in a Grievances and Appeals or case management setting
      • Preferably 5 years’ experience


    • Intermediate Ability to create, reviews, and interpret treatment plans.
    • Intermediate Ability to identify basic problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.
    • Intermediate Knowledge of medical terminology and/or experience with CPT and ICD-9/10 coding.
    • Intermediate Knowledge of community, state and federal laws and resources.
    • Intermediate Knowledge of CMS regulations and Medicare Rules.

    Licenses and Certifications:

    • Candidate will be a Registered Nurse.
    • Ideal candidate will have additional licenses or certifications related to BH/SUD.

    Technical Skills:

    • Required Intermediate Microsoft Excel Proficient in Microsoft Outlook applications, including Word, Excel, Power Point and Outlook
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word
    • Required Beginner Microsoft PowerPoint
    • Required Intermediate Experience with general Healthcare Management Systems
    • Ability to use proprietary healthcare management system


    • 1-2 years of experience in an acute care clinical setting (Medical and/or Behavioral Health).
    • 2 years of experience in Managed care experience with significant experience working in a settling like an inpatient psych unit or partial hospital, Residential BH or Substance Use Disorder services, Community Mental Health Organization or Opioid Treatment Program.

    Organizational Competencies:

    • Judgment and Decision Making
    • Gets Results
    • Collaboration and Teamwork
    • Business Awareness
    • Customer Focus

    Job Specific Competencies:

    • Attention to Detail
    • Resilience
    • Influencing & Negotiation
    • Planning & Organizing
    • Problem Solving & Analysis


    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org.


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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