Nurse Appeals

Elevance Health; Tennessee; On-site; USD 65,000 - 90,000; Full time

Job summary

Qualifications

• Minimum 2 years of experience in a managed care healthcare setting.
• Current active unrestricted RN license to practice.
• AS or BS in Nursing preferred.
• Ability to review medical records for medical necessity.

Responsibilities

• Investigate and review medical necessity appeals from members and providers.
• Review prospective, inpatient, or retrospective medical records for medical necessity.
• Summarize medical information for medical directors and external reviews.
• Apply guidelines to determine appropriate medical necessity for denied services.
• Assess, analyze and interpret medical information against criteria.
• Make determinations for payment approval using policy and benefits.
• Prepare recommendations to uphold or overturn requested appealed services.
• Forward recommendations to Medical Director for final decision.
• Ensure appeals/grievances meet regulatory timeframes.
• Document appeals in tracking and mainframe systems.

Skills

Managed care experience

Clinical analysis

Education

RN license

AS/BS in Nursing preferred

Tools

Mainframe systems

Job description

About This Role

The Nurse Appeals position is responsible for investigating and processing medical necessity appeals requests from members and providers. This role is ideal for individuals with a strong background in managed care healthcare settings.

Highlights

• Location: Nashville, TN

What You'll Do

• Conduct investigations and reviews of members and provider medical necessity appeals.
• Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Extrapolate and summarize medical information for medical directors, consultants, and other external reviews.
• Research to determine appropriate medical necessity guidelines to apply for denied services.
• Utilize guidelines and review tools to assess, analyze, and interpret medical information against criteria.
• Make determinations for payment approval using clinical criteria, medical policy, and benefit structure.
• Prepare recommendations to either uphold (deny) or overturn (approve) requested appealed services.
• Forward recommendations to Medical Director for final review and decision.
• Ensure that appeals and grievances are resolved timely to meet regulatory timeframes.
• Document and log appeal/grievance information on relevant tracking systems and mainframe systems.

Requirements

Education:

• HS diploma or equivalent required; AS or BS in Nursing preferred.

Experience:

• Minimum of 2 years of experience in a managed care healthcare setting.

Licenses & Certifications:

• Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) required.

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. They 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 their members and the communities they serve.