Registered Nurse- Managed Care (Hybrid) New

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