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. #AppealsNurse #MedicareAdvantage #Medicaid #ManagedCare #RemoteRN #NursingJobs