Nurse Appeals

Location: Richmond

Anticipated End Date:

Position Title:

Nurse Appeals

Job Description:

Nurse Appeals
- Licensed Nurse

Location:

Virtual:
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.

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.

Hours:

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.

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.

* 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 time frames.

* 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.

Minimum 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.

Preferred Skills, Capabilities and Experiences:

* AS or BS in Nursing preferred.

* Three to five years of clinical experience as a Registered Nurse strongly preferred.

* Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States 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.

For candidates working in person or virtually in the below locations, the salary
* range for this specific position is $72,492 to $108,738

Locations:
Latham, New York

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.

Job Level:

Non-Management Exempt

Workshift:

Job Family:

MED  Licensed Nurse

Please be advised that Elevance Health only accepts…