Nurse Appeals Senior

Nurse Appeals Senior

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 Senior is responsible for investigating and processing the most complex appeals requests from members and providers. They will be responsible for ensuring that appeals are resolved timely to meet regulatory time frames and generating appropriate written correspondence to providers, members, and regulatory entities.

• Conduct investigations and reviews of member and provider appeals.
• Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Extrapolate and summarize medical information for medical director, consultants and other external review.
• Prepare recommendations to either uphold or deny appeal and forward to Medical Director for approval.
• Document and log appeal information on relevant tracking systems and mainframe systems.
• Serve as technical resource to the team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.

• Requires a HS diploma or equivalent and a minimum of 4 years of experience in a managed care healthcare setting; or any combination of education and experience that would provide an equivalent background.
• Current active valid unrestricted RN professional within the scope of licensure in applicable state(s) or territory of the United States required.

• AS or BS in Nursing preferred.
• Experience in Medicare and G & A experience in health plan is strongly preferred.
• MCG experience is preferred.
• Strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills are highly preferred.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market‑competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member‑facing roles to…