Nurse Appeals RN

Elevance Health

91d

About The Position

The Nurse Appeals RN position is a hybrid role requiring 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. The Nurse Appeals RN is responsible for investigating and processing medical necessity appeals requests from members and providers. Primary duties include conducting investigations and reviews of member and provider medical necessity appeals, reviewing medical records of denied services, summarizing medical information for medical directors and consultants, preparing recommendations for appeals, ensuring timely resolution of appeals and grievances, documenting appeal information, generating written correspondence, and serving as a subject matter expert for appeals and grievances.

Requirements

• Requires a HS diploma or equivalent.
• Minimum of 2 years of experience in a managed care healthcare setting.
• 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.

Nice To Haves

• AS or BS in Nursing preferred.

Responsibilities

• Conduct investigations and reviews of member 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 director, consultants, and other external review.
• Prepare recommendations to either uphold or deny appeal and forward to Medical Director for approval.
• 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.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical benefits
• Dental benefits
• Vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees