Remote RN: Grievance & Appeals Specialist

Phaxis; New York (NY); À distance; USD 90 000 - 115 000; Plein temps

Résumé du poste

Phaxis is seeking an experienced RN for a fully remote payer-side role in New York. The candidate will own grievance and appeals from intake to final decision, applying medical necessity criteria and drafting auditable determinations.

The role focuses on outpatient, home health, and community-based services, not inpatient hospital denials. Ideal candidates have UM or case management background, familiarity with CMS and NY Medicaid rules, and strong clinical writing to support audit-ready letters

Qualifications

• Active, unrestricted New York State RN license. Compact or other state licenses alone do not qualify.
• 3+ years of progressive RN experience in healthcare.
• 2+ years working directly in grievance and appeals at a health plan, managed care organization or payer, where you personally investigated cases and drafted the determination.
• Utilization management and/or case management experience, so you can apply medical necessity criteria (such as InterQual or MCG) with confidence.
• Experience with outpatient, home health, community-based or long-term care services. Inpatient-only or hospital denials experience is not a match for this role.
• Working knowledge of CMS Medicare Part C appeals rules and/or New York Medicaid and MLTC grievance and appeals requirements.
• Strong clinical writing. You\'ll write letters members can understand and that hold up to audit.
• Comfortable managing multiple time-sensitive cases at once in a fully remote setting.

Responsabilités

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and member/provider notification.
• Review medical necessity, quality-of-care and long-term services and supports cases against plan benefits, clinical criteria and state and federal rules.
• Prepare case files for Medical Director review and work with the physician reviewer to reach a decision.
• Write clear, compliant determination letters to members and providers.
• Prepare and track external reviews, including New York State Fair Hearings, CMS Independent Review Entity cases and QIO reviews.
• Work with Claims, Utilization Management, the TPA and Legal to resolve cases.
• Review prior authorization requests where required for certain product lines.
• Meet strict CMS and New York State turnaround times, including expedited cases. This may mean occasional after-hours or weekend work.
• Document every action and rationale accurately for audit readiness.

Connaissances

Active NY RN license

3+ years RN experience

2+ years grievance & appeals

utilization management

case management

CMS Part C / NY Medicaid knowledge

clinical writing

Formation

BSN or MSN

Description du poste

Phaxis is seeking an experienced RN for a fully remote payer-side role in New York. The candidate will own grievance and appeals from intake to final decision, applying medical necessity criteria and drafting auditable determinations.

The role focuses on outpatient, home health, and community-based services, not inpatient hospital denials. Ideal candidates have UM or case management background, familiarity with CMS and NY Medicaid rules, and strong clinical writing to support audit-ready letters