phaxisNew York, NY
Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)
$52–$56/hr
Apply (opens in a new tab)Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)
Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)
phaxisNew York, NY
11 days ago
$52–$56/hr
Home Health Care ServicesNursing Care Facilities (Skilled Nursing Facilities)All Other Outpatient Care Centers
Apply for this role (opens in a new tab)Do you know the difference between an initial UM review and an appeal, and can you explain it to a Medical Director? We'd like to talk with you. A New York health plan needs a contract RN with hands-on experience handling payer-side grievances and appeals across Medicare Advantage, Medicaid and Managed Long Term Care.
Pay: $52–$56/hr based on experience
Location: 100% remote (U.S.)
License: Active, unrestricted NY RN license required
In this role you will:
- Investigate and decide clinical grievances, appeals and quality-of-care cases
- Review cases against plan benefits, clinical criteria and CMS/NYS rules
- Partner with physician reviewers to reach determinations
- Prepare and track NYS Fair Hearings, CMS IRE and QIO reviews
- Work with Claims, UM, the TPA and Legal to resolve cases
- Keep audit-ready documentation on every case You bring:
- 2+ years in grievance and appeals at a health plan or MCO, where you owned cases and wrote the determination letters
- A UM or case management foundation
- Outpatient, home health or LTSS experience (inpatient-only is not a match)
- Strong clinical writing skills
- 3+ years of total RN experience
Please note:
this is a payer-side role. Provider- or hospital-side appeals writing is not a match. Apply now or send me a message to learn more. Appeals Nurse #Medicare Advantage #Medicaid #Managed Care #RemoteRN #Nursing Jobs
Also on the board Same function, level within a rung
Level
Senior
Salary
$52–$56/hr
Location
New York, NY
Occupation
Registered Nurses
Industry
Home Health Care Services
Posted
11 days ago