Nurse Appeals

Elevance Health • Indianapolis, IN

5d • Remote

About The Position

Nurse Appeals Location: Indiana 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. The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers. How you will make an impact: Conducts investigations and reviews of member and provider medical necessity 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. Research to determine appropriate medical necessity guidelines to apply for denied services. Utilizes guidelines and review tools to assess, analyze, interpret the medical information against criteria and makes determination for payment approval using clinical criteria, medical policy, benefit structure and other determining factors, or prepares recommendations to either uphold (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision. 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. Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

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 Indiana is required.

Nice To Haves

• AS or BS in Nursing preferred.
• 3 years of clinical experience as a Registered Nurse is strongly preferred.
• Experience reviewing medical records, investigation, and/or processing appeals within a managed care setting is strongly preferred.
• Experience researching Medicaid and Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and MCG or other clinical criteria is strongly preferred.
• Experience reviewing claims and researching CPT codes or ICD-9/10 codes is strongly preferred.
• Experience with Facets, Macess, NextGen and ACMP is strongly preferred.
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

• Conducts investigations and reviews of member and provider medical necessity 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.
• Research to determine appropriate medical necessity guidelines to apply for denied services.
• Utilizes guidelines and review tools to assess, analyze, interpret the medical information against criteria and makes determination for payment approval using clinical criteria, medical policy, benefit structure and other determining factors, or prepares recommendations to either uphold (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.
• 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.
• Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

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: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees