[Hiring] Nurse Appeals @Elevance Health

Role Description

The Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers.

• Conduct investigations and reviews of members and provider medical necessity appeals.
• Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Extrapolate and summarize medical information for medical directors, consultants, and other external reviews.
• Research to determine appropriate medical necessity guidelines to apply for denied services.
• Utilize guidelines and review tools to assess, analyze, and interpret medical information against criteria.
• Make determinations for payment approval using clinical criteria, medical policy, benefit structure, and other determining factors.
• Prepare recommendations to either uphold (deny) or overturn (approve) requested appealed services and forward to Medical Director for final review and decision.
• Ensure that appeals and grievances are resolved timely to meet regulatory timeframes.
• Document and log appeal/grievance information on relevant tracking systems and mainframe systems.
• Generate written correspondence to providers, members, and regulatory entities.
• Utilize leadership skills and serve as a subject matter expert for appeals/grievances/quality of care issues.
• Act as a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

Qualifications

• Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience that would provide an equivalent background.
• Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

Requirements

• AS or BS in Nursing preferred.

Benefits

• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, and vision benefits.
• Short and long-term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.