Nurse Appeals (US)

Elevance Health•Cincinnati, OH

1d•Remote

About The Position

Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers. 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

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.

Nice To Haves

AS or BS in Nursing preferred.
Three to five years of clinical experience as a Registered Nurse strongly preferred.
Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
Experience with Facets, Macess, and ACMP is preferred.

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.
Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
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.