RN Grievance and Appeals - Health Plan

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.