RN (California) Nurse Appeals

Elevance Health•Sacramento, CA

2d•$35 - $57•Remote

About The Position

RN Nurse Appeals (California) Location: Must reside in California, Nevada, or Colorado. NOTE: Associates in this job working from a California location are eligible for overtime pay based on California employment law. 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 locations will not be considered for employment, unless an accommodation is granted as required by law. The Nurse Appeals is responsible for investigating and processing grievances from members and providers telephonically and through written correspondence/requests. Primary duties may include, but are not limited to: Conducts investigations and reviews of member and provider grievances. 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 grievances are resolved timely to meet regulatory timeframes. Documents and logs 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 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 valid unrestricted RN license to practice as a health professional within the scope of licensure in the state of California required.

Nice To Haves

Clinical experience in a variety of areas, i.e. ER, Med/Surg, Critical Care, primary practices.
Experience in document reviews and/or Utilization Review preferred.
Active RN license in additional states preferred.

Responsibilities

Conducts investigations and reviews of member and provider grievances.
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 grievances are resolved timely to meet regulatory timeframes.
Documents and logs 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 grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.