Nurse Appeals – Litigation & Legal Support

Elevance Health•Durham, NC

17d•Remote

About The Position

Nurse Appeals – Litigation & Legal Support In Office Expectation: This role is Virtual; This role enables associates to work virtually full-time, with the exception of 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. 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, 9:00AM – 6:00PM in your time zone; some flexibility in hours will be necessary and is dependent on court hearing schedules. The Nurse Appeals – Litigation & Legal Support is responsible for investigating and processing and medical necessity appeals requests from members and providers. How You Will Make an Impact Primary duties may include, but are not limited to: 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.
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.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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.
Ability to, and comfortability working with: internal and external legal counsel, medical directors, judges, and other management/leadership as necessary.
Proficiency in Microsoft Suite Products (e.g. Outlook, Excel, and Word).

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.
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
Ensuring all grievance processes are completed within regulatory timeframes.