Nurse Appeals Lead- RN

Elevance Health•Indianapolis, IN

1d•$102,948 - $154,421•Remote

About The Position

The Nurse Appeals Lead is responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers and provide leadership and work direction to other appeals staff. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

Requirements

Requires a HS diploma or equivalent and a minimum of 5 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

Current active valid 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.
AS or BS in Nursing preferred.

Responsibilities

Conducts investigations and reviews of member and provider grievances and appeals.
Reviews prospective or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for medical director, consultants and other external review.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
Generates written correspondence to providers, members, and regulatory entities.
Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.