Grievance & Appeals Nurse (RN)
About The Position
Nurse Appeals –Licensed Nurse Location : Ohio, candidates must be residents of Ohio to be considered. Hybrid 1 : This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule : Monday – Friday, 8:00AM – 5:00PM Eastern Time; some flexibility in hours will be necessary and is dependent on court hearing schedules. The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers. How You Will Make an Impact: ·Supports legal, management, and executive leadership by managing State Fair Hearing and External Medical Review requests. ·Acts as a resource for both clinical and non-clinical teams, by managing and conducting thorough investigations and reviews of medical necessity appeals from members and providers in preparation litigation. ·Documenting and logging appeal information in relevant tracking systems, generating written correspondence with members, providers, and regulatory entities, and serves as a subject matter expert for appeals, grievances, and quality of care issues. ·Key responsibilities: serves as a liaise with internal and external attorneys on regulatory cases, including ensuring accurate entry, investigation, and analysis of state appeals; summarizing medical information for review by medical directors and consultants; preparing recommendations to uphold or deny appeals; and ensuring all grievance processes are completed within regulatory timeframes.
Requirements
- 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, which 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.
Nice To Haves
- AS or BS in Nursing preferred.
- Background or exposure in litigation, legal proceedings, and/or paralegal experience is strongly desired.
- Understanding of the grievance and appeals process is strongly preferred.
- Basic knowledge of Medicare and Medicaid guidelines is preferred.
- Proficiency in Microsoft Suite Products (e.g. Outlook, Excel, and Word).
- Associates in this role are expected to have strong oral, written, and interpersonal communication skills, with an ability to problem-solve, organize, and execute tasks with minimal supervision.
- For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Responsibilities
- Supports legal, management, and executive leadership by managing State Fair Hearing and External Medical Review requests.
- Acts as a resource for both clinical and non-clinical teams, by managing and conducting thorough investigations and reviews of medical necessity appeals from members and providers in preparation litigation.
- Documenting and logging appeal information in relevant tracking systems, generating written correspondence with members, providers, and regulatory entities, and serves as a subject matter expert for appeals, grievances, and quality of care issues.
- Key responsibilities: serves as a liaise with internal and external attorneys on regulatory cases, including ensuring accurate entry, investigation, and analysis of state appeals; summarizing medical information for review by medical directors and consultants; preparing recommendations to uphold or deny appeals; and ensuring all grievance processes are completed within regulatory timeframes.
Benefits
- In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
- We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
