Remote RN Utilization & Appeals Specialist (Medicare/Medicaid)

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

Job summary

Phaxis is seeking an experienced registered nurse for a contract role with a New York health plan. You will own clinical grievances and appeals from intake to final decision letters, applying medical necessity judgments based on InterQual/MCG criteria.

The position is 100% remote in the United States, with business hours and occasional evenings or weekends to meet regulatory deadlines. Requires active NY RN license and payer-side experience.

Qualifications

• Active, unrestricted New York State RN license (compact alone does not qualify)
• 3+ years of RN experience
• 2+ years of payer-side grievance and appeals work where you personally investigated cases and drafted the determination
• UM and/or case management experience
• Outpatient, home health, community-based or long-term care background (not inpatient only)
• Working knowledge of Medicare Part C and/or NY Medicaid/MLTC appeals rules

Responsibilities

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification
• Apply medical necessity criteria (InterQual/MCG) to outpatient, home health, DME and LTSS cases
• Prepare case files for Medical Director review
• Write clear, compliant determination letters
• Prepare external reviews, including NYS Fair Hearings and CMS IRE/QIO cases
• Meet CMS and NYS turnaround times, including expedited cases

Skills

Clinical grievances & appeals

Medical necessity criteria

UM/case management

Job description

Phaxis is seeking an experienced registered nurse for a contract role with a New York health plan. You will own clinical grievances and appeals from intake to final decision letters, applying medical necessity judgments based on InterQual/MCG criteria.

The position is 100% remote in the United States, with business hours and occasional evenings or weekends to meet regulatory deadlines. Requires active NY RN license and payer-side experience.