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RN Grievance and Appeals - Health Plan

Phaxis
1 day ago
Remote
United States
$52 - $56 USD hourly
Administrative

RN Grievance & Appeals Specialist | Remote | Contract

RNs with direct, payer-side Grievance & Appeals experience — this opportunity is for you.

We’re seeking an RN who has personally managed clinical grievances and appeals from investigation through the final determination letter. This is a clinical review role requiring strong medical necessity knowledge, regulatory awareness, and the ability to manage strict deadlines.

Important: This is not a fit for candidates whose experience is limited to hospital denials, provider-side appeals, administrative support, or inpatient-only utilization review.

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.

If you meet the requirements and have personally owned payer-side grievance and appeals cases, apply with your current resume.

#PhaxisKimberlee