Nurse Appeals Senior

Elevance Health • Mason, OH

2d • Remote

About The Position

Nurse Appeals Senior Location: Virtual: 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. 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. Hours: The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis. The Nurse Appeals Senior is responsible for investigating and processing the most complex appeals requests from members and providers. will be responsible for ensuring that appeals are resolved timely to meet regulatory timeframes and generating appropriate written correspondence to providers, members, and regulatory entities. How you will make an impact: Conducts investigations and reviews of member and provider appeals. Reviews prospective, inpatient, 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. Documents and logs appeal information on relevant tracking systems and mainframe systems. Serves as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.

Requirements

• Requires a HS diploma or equivalent and a minimum of 4 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
• 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.

Nice To Haves

• AS or BS in Nursing preferred.
• Experience in Medicare and G & A experience in health plan is strongly preferred.
• MCG experience is preferred.
• Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills are highly preferred.

Responsibilities

• Conducts investigations and reviews of member and provider appeals.
• Reviews prospective, inpatient, 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.
• Documents and logs appeal information on relevant tracking systems and mainframe systems.
• Serves as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED