Local Contract Nurse RN - Case Management Insurance - $55-60 per hour

About the role

Phaxis is seeking a local contract RN Case Management Insurance specialist for a fully remote position in Manhattan, New York. The role is an RN Grievance and Appeals Specialist working days, 8‑hour shifts, Monday through Friday, 40 hours per week for a 20‑week contract starting 10/26/2026. The position requires an active NY RN license and prefers experience with Medicare/Medicaid, utilization management, prior authorization, grievance and appeals, and managed care.

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 background in Utilization Management, Prior Authorization, Grievance & Appeals, Managed Care.
• G&A experience is preferred but not mandatory.
• Must hold an active NY RN license.
• Temp assignment