RN Remote Grievance and Appeals

Phaxis • Manhattan, NY

1d • Remote

About The Position

Phaxis is looking for a dedicated Remote RN Grievance and Appeals Specialist in Manhattan, where your contributions will make a meaningful impact on patient care and overall clinic operations. We are looking for a reliable and detail-oriented individual who thrives in a dynamic environment.

Requirements

• Medicare and Medicaid experience preferred
• Strong backgrounds: Utilization Management
• Prior Authorization
• Grievance & Appeals
• NY RN License Temp (potential Perm)

Nice To Haves

• Managed Care G&A experience is preferred but not mandatory

Responsibilities

• Evaluate medical charts, prior authorizations, inpatient stays, and treatment histories against evidence-based guidelines like Milliman Care Guidelines (MCG) or InterQual.
• Examine why a service, procedure, or claim was reduced, terminated, or denied by an insurance payer or health system.
• Summarize clinical data and prepare case recommendations for physician consultants and medical directors to formally uphold or overturn an appeal.
• Track strict state and federal timeframes (such as CMS or state Department of Health guidelines) to ensure decisions and response letters are legally compliant.
• Communicate appeal outcomes and medical rationales clearly to members, families, providers, legal teams, and external review boards (like State Fair Hearings or Independent Review Entities).
• Identify recurring claim denial patterns or quality-of-care issues and report them to clinical leadership for process improvements.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level