RN Remote Grievance and Appeals

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.

Location - Fully Remote
Position - RN Grievance and Appeals Specialist
Schedule - Days, Monday through Friday
- 40 hours/week
- 20-week contract

Responsibilities

• Review Clinical Records: Evaluate medical charts, prior authorizations, inpatient stays, and treatment histories against evidence-based guidelines like Milliman Care Guidelines (MCG) or InterQual.
• Investigate Disputes: Examine why a service, procedure, or claim was reduced, terminated, or denied by an insurance payer or health system.
• Collaborate with Medical Directors: Summarize clinical data and prepare case recommendations for physician consultants and medical directors to formally uphold or overturn an appeal.
• Ensure Regulatory Compliance: Track strict state and federal timeframes (such as CMS or state Department of Health guidelines) to ensure decisions and response letters are legally compliant.
• Act as a Liaison: 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).
• Track Quality Trends: Identify recurring claim denial patterns or quality-of-care issues and report them to clinical leadership for process improvements

Requirements

• Medicare and Medicaid experience preferred
• Strong backgrounds:
  • Utilization Management
  • Prior Authorization
  • Grievance & Appeals
  • Managed Care
• G&A experience is preferred but not mandatory
• Will need an NY RN License

*Temp (potential Perm)

 If you are passionate about providing exceptional patient care and want to be part of a supportive team, we would love to hear from you!