Appeals Nurse Reviewer I

Elevance Health; Chicago (IL); Remote; USD 100,000 - 125,000; Full time

Job summary

A major healthcare company in Illinois seeks an Appeals Nurse Reviewer I. This role involves conducting reviews for appeal requests related to diagnostic imaging services. Candidates must have an AS in nursing and a current RN license, along with clinical nursing experience. This position offers a virtual work arrangement and competitive salary range of $34.69 to $54.41.

Benefits

Comprehensive benefits package

401k contribution

Equity stock purchase

Qualifications

• Requires AS in nursing and minimum of 3 years clinical nursing experience.
• Must have a current unrestricted RN license in applicable state(s).

Responsibilities

• Conduct reviews for diagnostic imaging services.
• Validate and manage appeal requests.
• Notify providers and members of appeal decisions.

Skills

Clinical nursing experience

Utilization management knowledge

ICD-9 and CPT-4 coding familiarity

Education

AS in nursing

BA/BS degree preferred

Job description

Overview

Anticipated End Date: 2025-10-10

Position Title: Appeals Nurse Reviewer I

Job Description:

Appeals Nurse Reviewer I

Location and Work Arrangement: This role enables associates to work virtually full-time, with the exception of required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location will not be considered for employment unless an accommodation is granted as required by law.

Work Schedule:

Monday through Friday: 11:30 AM - 8:00 PM, CST or PST (local time). Alternating weekends: 8:00 AM - 12:00 PM, CST/PST (local time) and some holidays included.

Elevance Health family of companies note: Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois.

Role purpose

The Appeals Nurse Reviewer I is responsible for conducting preauthorization, out-of-network, and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.

How you will make an impact

• Validating appeal requests.
• Manage Appeal requests that come via email, fax, mailed in letters, or live live.
• Opening and closing appeal requests following established appeal processes to maintain quality, turnaround time, and compliance requirements.
• Outreach to providers with appeal process instructions.
• Clinical review for the RBM and Surgical solution on a client specific basis.
• Notifying providers and/or members of appeal decisions.
• Maintain personal log all appeal requests assigned to ensure completion, as needed.
• Other duties as assigned.

Minimum Requirements

• Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
• A current unrestricted RN license in applicable state(s) required.

Preferred Experience, Skills, and Capabilities

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO and POS plans strongly preferred.
• BA/BS degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.

For candidates working in person or virtually in the below location(s), the salary range for this specific position is $34.69 to $54.41.

Locations: California, Illinois.

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.

Note on compensation language: 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. 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 Information

Job Level: Non-Management Non-Exempt

Workshift:

Job Family: MED > Licensed Nurse

Note: Elevance Health only accepts resumes for compensation from agencies with a signed agreement. Unsolicited resumes are the property of Elevance Health.

About Elevance Health

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 who are passionate about making an impact on our members and the communities we serve.

How We Work

We are creating a culture that advances our strategy and supports personal and professional growth. Our values and behaviors drive our culture, shape our strategy, power business outcomes, and foster shared success for consumers, associates, communities, and the business.

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

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 possibly several times per week. Specific onsite expectations will be discussed during the hiring process.

Vaccination policy: New candidates in certain patient/member-facing roles may be required to be vaccinated against COVID-19 and Influenza. If not vaccinated, an offer may be rescinded unless an acceptable explanation is provided. Elevance Health will follow all relevant federal, state, and local laws.

Elevance Health is an Equal Employment Opportunity employer. All qualified applicants will receive consideration without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable laws. Applicants who require accommodation to participate in the job application process may contact [e-mail] for assistance. Qualified applicants with arrest or conviction records will be considered in accordance with the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.