Nurse Appeals

Elevance Health•Nashville, TN

3d•Remote

About The Position

The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers.

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.

Conduct investigations and reviews of members 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 directors, consultants and other external reviews.
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.