RN Grievance and Appeals - Health Plan

RN Grievance & Appeals Specialist | Remote | Contract

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.

Required experience:

• 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.

If you meet the requirements and have personally owned payer-side grievance and appeals cases, apply with your current resume.

#PhaxisKimberlee