Remote RN Utilization Management & Appeals Reviewer (NY RN License Required)

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

You've done UM. You've worked appeals. Now find a role that uses both. We're hiring a contract RN for a New York health plan (Medicare Advantage, Medicaid and MLTC). You'll own clinical grievances and appeals from intake to final decision letter, and you'll apply the same medical necessity judgment you built in utilization management.

100% remote (U.S.) | Contract | $52–$56/hr based on experience Business hours, with occasional evening or weekend coverage for regulatory deadlines

What you'll do:

• 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

What you need:

• 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

Nice to have:

• BSN/MSN, CCM or CPHQ, dual-eligible experience