Remote RN: Payer-side Grievances & Appeals Specialist

Phaxis; New York (NY); Remote; USD 90,000 - 120,000; Full time

Job summary

Phaxis is seeking an experienced RN to own grievance and appeals cases from intake through final determination for a New York health plan. The role focuses on outpatient and community-based services, with emphasis on medical necessity, regulatory compliance, and external reviews.

This is a fully remote opportunity requiring strong clinical writing and audit readiness. The ideal candidate has 3+ years in RN practice and 2+ years directly handling grievance/appeals at a payer, CMS/Medicaid

Qualifications

• Active, unrestricted New York RN license.
• 3+ years progressive RN experience in healthcare.
• 2+ years working directly in grievance and appeals at a health plan.
• Familiarity with CMS/Medicare Part C & Medicaid/MLTC rules.
• Remote work capability and strong written communication.

Responsibilities

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification.
• Review medical necessity and quality-of-care cases against plan benefits and criteria.
• Prepare case files for Medical Director review and coordinate with physician reviewers.
• Write clear, compliant determination letters for members and providers.
• Prepare and track external reviews (NYS Fair Hearings, CMS IRE/QIO).
• Collaborate with Claims, Utilization Management, and Legal to resolve cases.
• Review prior authorization requests where applicable.
• Meet CMS and NY turnaround times; some after-hours/weekends may be required.
• Document actions and rationale for audit readiness.

Skills

Clinical documentation

Medical necessity criteria

Audit readiness

Multi-case management

Education

BSN

MSN

Tools

Word

Excel

Job description

Phaxis is seeking an experienced RN to own grievance and appeals cases from intake through final determination for a New York health plan. The role focuses on outpatient and community-based services, with emphasis on medical necessity, regulatory compliance, and external reviews.

This is a fully remote opportunity requiring strong clinical writing and audit readiness. The ideal candidate has 3+ years in RN practice and 2+ years directly handling grievance/appeals at a payer, CMS/Medicaid