Elevance Health
Location
Indiana
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 location(s) will not be considered for employment, unless an accommodation is granted as required by law.
The Nurse Appeals 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 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.
Research to determine appropriate medical necessity guidelines to apply for denied services.
Utilizes guidelines and review tools to assess, analyze, interpret the medical information against criteria and makes determination for payment approval using clinical criteria, medical policy, benefit structure and other determining factors, or prepares recommendations to either uphold (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
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 Indiana is required.
Preferred Capabilities, Skills, And Experiences
AS or BS in Nursing preferred.
3 years of clinical experience as a Registered Nurse is strongly preferred.
Experience reviewing medical records, investigation, and/or processing appeals within a managed care setting is strongly preferred.
Experience researching Medicaid and Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and MCG or other clinical criteria is strongly preferred.
Experience reviewing claims and researching CPT codes or ICD‑9/10 codes is strongly preferred.
Experience with Facets, Macess, NextGen and ACMP is strongly preferred.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
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, and 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
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 location(s) will not be considered for employment, unless an accommodation is granted as required by law.
The Nurse Appeals 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 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.
Research to determine appropriate medical necessity guidelines to apply for denied services.
Utilizes guidelines and review tools to assess, analyze, interpret the medical information against criteria and makes determination for payment approval using clinical criteria, medical policy, benefit structure and other determining factors, or prepares recommendations to either uphold (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
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 Indiana is required.
Preferred Capabilities, Skills, And Experiences
AS or BS in Nursing preferred.
3 years of clinical experience as a Registered Nurse is strongly preferred.
Experience reviewing medical records, investigation, and/or processing appeals within a managed care setting is strongly preferred.
Experience researching Medicaid and Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and MCG or other clinical criteria is strongly preferred.
Experience reviewing claims and researching CPT codes or ICD‑9/10 codes is strongly preferred.
Experience with Facets, Macess, NextGen and ACMP is strongly preferred.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem‑solving skills, facilitation skills, and analytical skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
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, and 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