RN Utilization Management & Appeals Nurse (Remote, NY License)

Job Description

Job Description

About the role

We're looking for an RN who has personally owned grievance and appeals cases from intake to final decision letter. Not someone who supported the team, but someone who built the case file, applied the criteria, met the clock and defended the outcome.

Our client is a New York health plan. You'll handle clinical grievances, appeals and external reviews for members receiving outpatient and community-based care: home health, long-term services and supports, outpatient procedures, DME and similar services. This is not an inpatient or hospital-based role.

The best fit has a utilization management or case management foundation and has moved into payer-side grievance and appeals work, so you understand both medical necessity and the regulatory process around it.

What you'll do

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and member/provider notification.
• Review medical necessity, quality-of-care and long-term services and supports cases against plan benefits, clinical criteria and state and federal rules.
• Prepare case files for Medical Director review and work with the physician reviewer to reach a decision.
• Write clear, compliant determination letters to members and providers.
• Prepare and track external reviews, including New York State Fair Hearings, CMS Independent Review Entity cases and QIO reviews.
• Work with Claims, Utilization Management, the TPA and Legal to resolve cases.
• Review prior authorization requests where required for certain product lines.
• Meet strict CMS and New York State turnaround times, including expedited cases. This may mean occasional after-hours or weekend work.
• Document every action and rationale accurately for audit readiness.

Must-haves

• Active, unrestricted New York State RN license. Compact or other state licenses alone do not qualify.
• 3+ years of progressive RN experience in healthcare.
• 2+ years working directly in grievance and appeals at a health plan, managed care organization or payer, where you personally investigated cases and drafted the determination.
• Utilization management and/or case management experience, so you can apply medical necessity criteria (such as InterQual or MCG) with confidence.
• Experience with outpatient, home health, community-based or long-term care services. Inpatient-only or hospital denials experience is not a match for this role.
• Working knowledge of CMS Medicare Part C appeals rules and/or New York Medicaid and MLTC grievance and appeals requirements.
• Strong clinical writing. You'll write letters members can understand and that hold up to audit.
• Comfortable managing multiple time-sensitive cases at once in a fully remote setting.

Nice to haves

• BSN or MSN.
• Experience with New York State Fair Hearings or CMS IRE/QIO external reviews.
• Medicare Advantage and Medicaid managed care (dual-eligible) experience.
• CCM, CPHQ or similar certification.
• Experience with appeals tracking systems, plus solid Word and Excel skills.

This role is probably not for you if

• Your appeals experience is on the provider or hospital side (for example, writing appeals to payers for denied claims).
• You've supported a G&A team administratively but haven't made or drafted the clinical determination.
• Your UM or case management work has been inpatient or acute care only.
• You don't currently hold a New York RN license.