Remote UM / Grievance & Appeals RN – NY Licensed

Phaxis; New York (NY); À distance; USD 72 000 - 77 000; Temps partiel

Avantages offerts par ce poste

100% remote

Résumé du poste

Phaxis is hiring a Remote UM / Grievance & Appeals RN (NY License) for a contract role with a New York health plan. If you have owned appeals from intake to final decision letter, we want to talk to you.

You will review medical necessity for outpatient and community-based services, draft determination letters, and prepare cases for Fair Hearings and CMS external reviews. A NY RN license and payer-side experience are required.

Qualifications

• Active, unrestricted New York RN license.
• 2+ years of payer-side grievance and appeals experience.
• UM or case management experience (InterQual/MCG).
• Outpatient, home health or LTC experience; not inpatient-only.
• Knowledge of CMS and NY Medicaid/MLTC appeals rules.

Responsabilités

• Review medical necessity for outpatient and community-based services.
• Write determination letters and related documentation.
• Prepare cases for Fair Hearings and CMS external reviews.

Connaissances

RN license

Payer-side appeals

Utilization management

InterQual/MCG

Outpatient/Home health/LTC

CMS NY Medicaid/MLTC rules

Outils

InterQual/MCG

Description du poste

Now hiring: Remote UM / Grievance & Appeals RN (NY License) | Contract | $52-56/hr

Are you an RN who has owned appeals cases from intake to final decision letter? We want to talk to you.

Our client, a New York health plan, needs a clinical Grievance & Appeals nurse with a utilization management or case management background. You’ll review medical necessity for outpatient and community-based services such as home health, long-term care, DME and outpatient procedures. You’ll also work with the Medical Director, write determination letters, and prepare cases for Fair Hearings and CMS external reviews.

What you need:

• Active, unrestricted New York RN license
• 2+ years of payer-side grievance & appeals experience, where you made or drafted the clinical decision
• UM or case management experience (InterQual/MCG)
• Outpatient, home health or LTC experience (not inpatient-only)
• Knowledge of CMS and/or NY Medicaid/MLTC appeals rules

What you get:

• 100% remote
• $52-56/hour, depending on experience
• Contract role with a respected health plan