RN Grievance and Appeals - Health Plan

Phaxis; New York (NY); Teletrabalho; USD 72 000 - 77 000; Tempo parcial

Resumo da oferta

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

Qualificações

• 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.

Responsabilidades

• 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.

Conhecimentos

Grievance investigations

Clinical documentation

Regulatory knowledge

Medical necessity criteria

Clinical writing

Case management

Independent work

Formação académica

Registered Nurse licensing (NY)

Descrição da oferta de emprego

Position details:

Pay: $52-$56/hour, based on experience Type: Contract Location: 100% remote within the U.S. Schedule: Business hours, with occasional evening or weekend coverage to meet regulatory deadlines

The role:

Investigate and manage clinical grievances, appeals, and external reviews from intake to resolution. Review medical necessity, quality-of-care concerns, and outpatient, home health, DME, and long-term services and supports cases. Collaborate with Medical Directors and prepare clear, compliant determination letters. Coordinate external reviews, including NYS Fair Hearings, CMS IRE, and QIO reviews. Manage multiple cases while meeting strict regulatory turnaround times.

Required experience:

Active, unrestricted New York State RN license. 3+ years of progressive RN experience. 2+ years of direct health plan/payer-side grievance and appeals experience, including personally investigating cases and drafting determination letters. Utilization management and/or case management experience, with knowledge of medical necessity criteria such as InterQual or MCG. Experience with outpatient, home health, community-based, or long-term care services. Knowledge of CMS Medicare Advantage and/or New York Medicaid/MLTC grievance and appeals requirements. Strong clinical writing, documentation, and case-management skills.