Elevance Health
2 days ago Be among the first 25 applicants
Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.
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.
Expected Work Hours: Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time
The Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers.
How you will make an impact:
Conducts investigations and reviews of member grievances and Quality of Care cases.
Reviews medical records for member grievance concerns and Quality of Care cases.
Extrapolates and summarizes medical information for medical director.
Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination.
Ensures 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.
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.
Multi-state/compact RN license preferred.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
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Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.
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.
Expected Work Hours: Monday-Friday, 8:00AM -5:00 PM Eastern Standard Time
The Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers.
How you will make an impact:
Conducts investigations and reviews of member grievances and Quality of Care cases.
Reviews medical records for member grievance concerns and Quality of Care cases.
Extrapolates and summarizes medical information for medical director.
Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination.
Ensures 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.
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.
Multi-state/compact RN license preferred.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
#J-18808-Ljbffr