Nurse Appeals

Elevance Health•Nashville, TN

2d•Remote

About The Position

The Nurse Appeals is responsible for investigating and processing medical necessity appeal requests from members and providers. This role conducts clinical reviews of denied services, researches and applies appropriate medical necessity guidelines, and prepares recommendations or determinations based on clinical criteria, medical policy, benefit structure, and other relevant factors. Recommendations to uphold or overturn an appeal are forwarded to a Medical Director for final review and decision when applicable. The role also ensures timely resolution of appeals and grievances, maintains case documentation, generates written correspondence, and serves as a subject matter expert and resource for team members. The role is open only to residents of Tennessee and is primarily virtual full-time, with required in-person training sessions. Candidates must live within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law.

Requirements

High school diploma or equivalent and at least 2 years of experience in a managed care healthcare setting, or an equivalent combination of education and experience.
Current active, unrestricted RN license to practice as a health professional within the scope of licensure in applicable U.S. state(s) or territory.
Must be a resident of Tennessee.
Must be within reasonable commuting distance of the posting location for required in-person training, unless accommodation is granted as required by law.

Nice To Haves

Associate of Science or Bachelor of Science in Nursing preferred.

Responsibilities

Conduct investigations and reviews of members’ and providers’ medical necessity appeals.
Review prospective, inpatient, or retrospective medical records for services denied on medical necessity grounds.
Extract and summarize medical information for medical directors, consultants, and external reviews.
Research and determine the appropriate medical necessity guidelines for denied services.
Use guidelines and review tools to assess, analyze, and interpret medical information against criteria.
Make payment approval determinations using clinical criteria, medical policy, benefit structure, and other determining factors, or prepare recommendations to uphold or overturn the appealed service and forward them to a Medical Director for final review and decision.
Ensure appeals and grievances are resolved timely to meet regulatory timeframes.
Document and log appeal and grievance information in relevant tracking and mainframe systems.
Generate written correspondence to providers, members, and regulatory entities.
Serve as a subject matter expert for appeals, grievances, and quality-of-care issues, and support clinical and non-clinical team members in resolving outstanding issues.