[Hiring] RN Grievance and Appeals Specialist @Phaxis

Role Description

RNs 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 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.

Qualifications

• 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.

Requirements

• Must meet the qualifications listed above.

Benefits

• Competitive pay based on experience.
• Remote work flexibility.
• Opportunity to work in a clinical review role.