Remote RN Utilization Management & Appeals Reviewer; NY RN

You've done UM. You've worked appeals. Now find a role that uses both. 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

• Own a caseload of clinical grievances and appeals end to end: intake, investigation, clinical review, decision and notification
• Apply medical necessity criteria (Inter Qual/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

• 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

• BSN/MSN, CCM or CPHQ, dual-eligible experience