Clinical Appeals Nurse Medicare Advantage & Medicaid Managed Care (Remote)

Do 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.

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