Nurse Appeals

Elevance Health (Anthem); Nashville (TN); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Healthcare benefits

401(k) + match

Stock purchase plan

Job summary

Elevance Health in Nashville, Tennessee is seeking a Nurse Appeals professional to investigate and process medical necessity appeals from members and providers. The role reviews inpatient, prospective or retrospective records, applies policy guidelines, and prepares recommendations for approval or denial, escalating to the Medical Director for final decisions.

Minimum requirements include a HS diploma or equivalent and an active RN license; AS or BS in Nursing is preferred.

Qualifications

• HS diploma or equivalent required; RN license active in applicable state(s).
• AS or BS in Nursing preferred.
• Minimum 2 years in a managed care healthcare setting or equivalent experience.

Responsibilities

• Investigate and process medical necessity appeals for members and providers.
• Review prospective, inpatient, or retrospective medical records for medical necessity.
• Extrapolate and summarize medical information for medical directors and external reviews.
• Research applicable medical necessity guidelines to determine applicable criteria.
• Apply clinical criteria and policy to determine payment decisions or prepare recommendations for approval/denial.
• Ensure timely resolution of appeals to meet regulatory timeframes; document in tracking systems.
• Generate written correspondence to providers, members, and regulatory entities.
• Serve as SME for appeals/grievances and assist team members in issue resolution.

Education

HS diploma or equivalent

RN license

AS or BS in Nursing

Job description

Position Title

Nurse Appeals

Location

Nashville Tennessee (This role is open only to residents of Tennessee).

Work Arrangement

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.

Hybrid/Virtual Policy

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 accommodation is granted as required by law.

Role Overview

The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers.

How you will make an impact

• Conduct investigations and reviews of members 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 directors, consultants and other external reviews.
• 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 applicable state(s) or territory of the United States required.

Preferred Skills, Capabilities and Experiences

• AS or BS in Nursing preferred.

Job Level

Non-Management Exempt

Job Family

MED > Licensed Nurse

Agency Resume Policy

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.

Who We Are

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.

How We Work

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.

Benefits and Compensation

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.

Hybrid Workforce Strategy

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.

COVID-19 and Influenza Vaccination

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 become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Equal Employment Opportunity

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment withou