Remote RN Utilization Management & Appeals Reviewer (NY RN License Required)

Contract RN For New York Health PlanYou've done UM. You've worked appeals. Now find a role that uses both. We're hiring a contract RN for a New York health plan (Medicare Advantage, Medicaid and MLTC). You'll own clinical grievances and appeals from intake to final decision letter, and you'll apply the same medical necessity judgment you built in utilization management. 100% remote (U.S.) | Contract | $52–$56/hr based on experience Business hours, with occasional evening or weekend coverage for regulatory deadlinesWhat you'll do:Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notificationApply medical necessity criteria (InterQual/MCG) to outpatient, home health, DME and LTSS casesPrepare case files for Medical Director reviewWrite clear, compliant determination lettersPrepare external reviews, including NYS Fair Hearings and CMS IRE/QIO casesMeet CMS and NYS turnaround times, including expedited casesWhat you need:Active, unrestricted New York State RN license (compact alone does not qualify)3+ years of RN experience2+ years of payer-side grievance and appeals work where you personally investigated cases and drafted the determinationUM and/or case management experienceOutpatient, home health, community-based or long-term care background (not inpatient only)Working knowledge of Medicare Part C and/or NY Medicaid/MLTC appeals rulesNice to have: BSN/MSN, CCM or CPHQ, dual-eligible experience