Nurse Appeals

Elevance Health; Columbus, Northern (OH, KY); Hybrid; USD 39,000 - 74,000; Full time

Benefits offered by this job

Major medical insurance

HSA

Dental insurance

Vision insurance

Life insurance

Disability insurance

401k

Job summary

Elevance Health is seeking a qualified registered nurse to investigate and process medical necessity appeals from members and providers. This contract role requires an active RN license and at least 2 years of managed care experience, with URAC competencies preferred.

The position supports a hybrid workforce model and may involve state-specific market requirements. Ideal candidates will demonstrate strong written communication, analytical thinking, and the ability to collaborate with medical

Qualifications

• Requires HS diploma or equivalent and 2+ years in a managed care setting.
• Active RN license to practice (US) required; AS/BS in Nursing preferred.
• URAC competencies and strong communication, problem-solving, and analytical skills.

Responsibilities

• Investigates and processes medical necessity appeals for members and providers.
• Extrapolates and summarizes medical information for medical directors and consultants.
• Prepares recommendations to uphold or deny appeals for approval.
• Ensures timely resolution to meet regulatory timeframes; documents tracking.
• Generates correspondence to providers, members, and regulators.
• Acts as SME for appeals/grievances and quality-of-care issues.

Skills

RN license active

Clinical reviews

Managed care experience

Strong written communication

Education

HS diploma or equivalent

AS/BS in Nursing preferred

Active RN license in US

Job description

Anticipated Start Date: November 2, 2026

Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.

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.

Responsible for investigating and processing and medical necessity appeals requests from members and providers.

Primary duties may include, but are not limited to:

• 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 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.

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. AS or BS in Nursing preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Type

Contract

IDEAL PREFERRED SCHEDULE: Tuesday-Saturday (8am-5pm), However, open to Monday-Friday (8am-5pm).

Managed Care, Clinical reviews

MCG and CMS guidelines experience preferred.

Review all markets, will be required to be fingerprinted for Florida markets.

Candidates must be within a reasonable commute to a PulsePoint location.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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.

About BCForward

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Pay Rate Range

Min Pay Rate $28.01

Max Pay Rate $53.48

Currency USD

Unit hourly

Additional Pay Rate Notes

The pay range is the range BCForward 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.

Benefits Information

BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.

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. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).