[Hiring] Utilization Management & Appeals Reviewer @Phaxis

Role Description

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 deadlines.

What you'll do:

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification
• Apply medical necessity criteria (InterQual/MCG) to outpatient, home health, DME and LTSS cases
• Prepare case files for Medical Director review
• Write clear, compliant determination letters
• Prepare external reviews, including NYS Fair Hearings and CMS IRE/QIO cases
• Meet CMS and NYS turnaround times, including expedited cases

Qualifications

• Active, unrestricted New York State RN license (compact alone does not qualify)
• 3+ years of RN experience
• 2+ years of payer-side grievance and appeals work where you personally investigated cases and drafted the determination
• UM and/or case management experience
• Outpatient, home health, community-based or long-term care background (not inpatient only)
• Working knowledge of Medicare Part C and/or NY Medicaid/MLTC appeals rules

Requirements

• Nice to have: BSN/MSN, CCM or CPHQ, dual-eligible experience

Company Description

Interested? Apply here or message me directly.

Email: [email protected]

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