RN Grievance and Appeals - Health Plan

RN Grievance & Appeals Specialist | Remote | ContractRNs 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 experienceType: ContractLocation: 100% remote within the U.S.Schedule: Business hours, with occasional evening or weekend coverage to meet regulatory deadlinesThe 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.