Remote NY RN Grievance & Appeals Specialist

Phaxis; New York (NY); Remote; USD 90,000 - 130,000; Full time

Job summary

Phaxis is seeking an experienced RN to own grievance and appeals cases from intake to final decision in a fully remote setting. You will handle outpatient and community-based care grievances, applying medical necessity criteria and regulatory rules.

The ideal candidate has 3+ years in RN grievance/appeals, familiarity with CMS Part C and NY Medicaid/MLTC, and strong clinical writing. Prior utilization/case management foundation preferred, with ability to manage multiple cases under tight

Qualifications

• Active, unrestricted New York RN license required.
• 3+ years progressive RN experience in healthcare.
• 2+ years in grievance and appeals at a health plan or payer.
• Experience with utilization management and/or case management.
• Knowledge of CMS Medicare Part C rules and NY Medicaid/MLTC requirements.
• Strong clinical writing and auditable determination letters.
• Remote work ability with time-sensitive cases.
• Inpatient or hospital denial experience is not a match.

Responsibilities

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification.
• Review medical necessity, quality-of-care and long-term services against plan benefits and criteria.
• Prepare case files for Medical Director review and coordinate with physician reviewer to reach a decision.
• Write clear, compliant determination letters to members and providers.
• Prepare and track external reviews (NY State Fair Hearings, CMS IRE/QIO).
• Collaborate with Claims, Utilization Management, the TPA and Legal to resolve cases.
• Meet CMS and NYS turnaround times, including after-hours or weekend work.
• Document every action and rationale for audit readiness.

Skills

RN license NY

Grievances & appeals

Utilization management

Case management

CMS Medicare rules

Clinical writing

Remote work

Education

BSN or MSN

Tools

MS Word

Excel

Job description

Phaxis is seeking an experienced RN to own grievance and appeals cases from intake to final decision in a fully remote setting. You will handle outpatient and community-based care grievances, applying medical necessity criteria and regulatory rules.

The ideal candidate has 3+ years in RN grievance/appeals, familiarity with CMS Part C and NY Medicaid/MLTC, and strong clinical writing. Prior utilization/case management foundation preferred, with ability to manage multiple cases under tight