RN Grievance and Appeals Health Plan

RN Grievance & Appeals Specialist Remote Contract

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

Were 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