Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)
phaxisNew York, NY
$52–$56/hr
Apply now (opens in a new tab)Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)
L5
phaxisNew York, NY14 days ago
$52–$56/hr
Industries
Home Health Care ServicesNursing Care Facilities (Skilled Nursing Facilities)All Other Outpatient Care CentersDo 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
Apply now (opens in a new tab)
Level
SeniorL5
Salary
$52–$56/hr
Location
New York, NY
Occupation
Registered Nurses
Industry
Home Health Care Services
Posted
14 days ago
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