For more than 30 years, this health plan has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Appeals Nurse / Utilization Management and Appeals / Remote...

Experience
• Required: Strong background in Appeals and Grievances management.
• Experience in Utilization Management (UM) or Appeals within the NYC metro area.
• Required: A valid New York State Nursing License (RN or LPN).

Position Details:
• Schedule: Monday through Friday, business hours.
• Employment Type: Full-time, Permanent.
• Location: Remote (One-day onboarding in NYC office, followed by 100% remote work).

Benefits:
• Generous benefits package, including a Pension Plan.
• Competitive salary up to $108,500+.

Position Overview: The Appeals Nurse will work under the direction of the Vice President of Clinical Services, focusing on managing and resolving appeals and grievances in line with regulatory requirements. Additionally, the Appeals Nurse will play a key role in the Utilization Management (UM) process, ensuring that medical services are provided efficiently while maintaining high-quality patient care outcomes.

Key Responsibilities
• Lead the appeals and grievances process by reviewing, evaluating, and responding to member and provider appeals in a timely and compliant manner.
• Conduct medical necessity reviews for appeals, collaborating with the Physician Advisor and other clinical staff when necessary.
• Investigate grievances by analyzing medical records, member data, and provider reports to ensure proper resolution.
• Coordinate with internal departments to ensure all appeal determinations comply with regulatory agency guidelines and contractual requirements.
• Maintain accurate documentation and records of appeals and grievances activities, including decisions and communications.
• Perform Utilization Management activities, including hospital admission certification, continued stay reviews, and outpatient service approvals in accordance with established UM policies.
• Facilitate discharge planning and care coordination to ensure members receive appropriate care in the most cost-effective setting.
• Communicate UM and appeal determinations to members and providers, including alternative treatment options as needed.
• Participate in cross-functional team meetings and medical management rounds to discuss complex cases and ensure alignment in care planning.

Minimum Qualifications:
• High School Diploma or GED required.
• 2-5 years’ clinical experience in an acute or relevant care setting.
• Demonstrated experience with Appeals and Grievances in a managed care or hospital setting.
• Prior experience in Utilization Management or Utilization Review (UM/UR).
• Active New York State Nursing License (RN or LPN) License.

Benefits:
• Comprehensive benefits package including a pension plan.
• Competitive salary up to $108,500