Remote RN Grievance & Appeals Specialist

Phaxis; New York (NY); Remote; USD 72,000 - 77,000; Part time

Job summary

Phaxis is seeking an experienced registered nurse to investigate and manage clinical grievances, appeals, and external reviews from intake to resolution. The role emphasizes reviewing medical necessity, quality-of-care concerns, and coordination across settings from outpatient to long-term care, all within regulatory deadlines.

You will collaborate with Medical Directors, draft determination letters, and coordinate external reviews including NYS Fair Hearings, CMS IRE, and QIO reviews, while

Qualifications

• Active, unrestricted New York State RN license.
• 3+ years progressive RN experience.
• 2+ years direct health plan/payer grievance & appeals, including drafting determination letters.
• Utilization management and/or case management experience with InterQual or MCG.
• Experience with outpatient, home health, or long-term care services.
• Knowledge of CMS Medicare Advantage and NY Medicaid/MLTC grievance requirements.
• Strong clinical writing, documentation, and case-management skills.

Responsibilities

• Investigate and manage clinical grievances, appeals, and external reviews from intake to resolution.
• Review medical necessity and quality-of-care concerns across care settings (outpatient, home health, DME, long-term services).
• Collaborate with Medical Directors and prepare clear, compliant determination letters.
• Coordinate external reviews (NYS Fair Hearings, CMS IRE, QIO) as needed.
• Manage multiple cases with timely regulatory turnaround.

Skills

Grievance investigations

Clinical documentation

Regulatory knowledge

Medical necessity criteria

Clinical writing

Case management

Independent work

Education

Registered Nurse licensing (NY)

Job description

Phaxis is seeking an experienced registered nurse to investigate and manage clinical grievances, appeals, and external reviews from intake to resolution. The role emphasizes reviewing medical necessity, quality-of-care concerns, and coordination across settings from outpatient to long-term care, all within regulatory deadlines.

You will collaborate with Medical Directors, draft determination letters, and coordinate external reviews including NYS Fair Hearings, CMS IRE, and QIO reviews, while