A healthcare organization in New York City is seeking a Registered Nurse (RN) to join its Appeals & Grievances (A&G) team. This is a Hybrid, non-clinical role focused on clinical case review and regulatory compliance.

About the Opportunity:
- Start Date: ASAP
- Schedule: Monday to Friday
- Hours: Full-time, daytime hours
- Setting: Hybrid (4 days remote, 1 day onsite in Manhattan)
Responsibilities:
- Review and investigate member/provider appeals, grievances, and medical necessity cases
- Ensure cases meet CMS/DOH timelines and regulatory guidelines
- Conduct clinical documentation reviews and prepare case summaries
- Support internal and external reviews (e.g., internal medical review, Maximus/IRE, Fair Hearings, External Appeals)
- Draft acknowledgment letters, request additional information, and issue determination notices
- Coordinate with internal teams such as Claims, Customer Service, Billing, Enrollment, and Medical Management
- Maintain accurate documentation in internal case management systems
Qualifications:
- 2+ years of experience in Managed Care, Utilization Review, Case Management, Appeals/Denials, or Quality Assurance
- Graduate of an accredited School of Nursing
- NYS Registered Nurse (RN) license
- Strong documentation review and clinical writing skills
- Familiarity with CMS/DOH regulations
- Proficient with EMRs and Microsoft Office
- Proven skills in Clinical Nursing
