Nurse Appeals

Elevance Health; Nashville (TN); Híbrido; USD 70.000 - 90.000; Jornada completa

Descripción de la vacante

Elevance Health in Nashville, TN seeks an RN with managed care experience to investigate and process medical necessity appeals from members and providers. The role combines clinical review with documentation and regulatory compliance, with virtual work options and mandatory in-person training sessions.

Responsibilities include reviewing records, applying guidelines, making determinations, and generating communications to stakeholders.

Formación

• Requires HS diploma or equivalent with 2+ years in a managed care healthcare setting.
• Current active unrestricted RN license in applicable state(s) required.
• AS or BS in Nursing preferred.

Responsabilidades

• Conduct investigations and reviews of members and provider medical necessity appeals.
• Review prospective, inpatient, or retrospective medical records for medical necessity.
• Extrapolate and summarize medical information for medical directors and external reviews.
• Research to determine applicable medical necessity guidelines for denied services.
• Assess, interpret and decide on payment approval using clinical criteria and policy.
• Prepare recommendations to uphold or overturn requested services and forward to Medical Director.
• Ensure timely resolution of appeals to meet regulatory timeframes.
• Document and log appeal information on relevant tracking systems and mainframes.
• Generate written correspondence to providers, members, and regulatory entities.

Conocimientos

RN license

Managed care experience

Educación

HS diploma or equivalent

AS or BS in Nursing preferred

Descripción del empleo

Nurse Appeals

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

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.

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.

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.

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.

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.

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.

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.

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 should submit the Accessibility Accommodation Request Form and a member of the team will be in contact.

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.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.