Nurse Appeals (contract)

Elevance Health; Indianapolis (IN); Hybrid; USD 39,000 - 74,000; Full time

Job summary

Elevance Health is seeking an experienced RN with strong clinical and analytical skills to investigate and process medical necessity appeals from members and providers. You will review various medical records, summarize findings for the medical director, and prepare recommendations to uphold or deny the appeal.

This role is 100% remote with Maryland licensure required and a hybrid workforce strategy for onsite requirements as needed.

Qualifications

• HS diploma or equivalent; 2+ years in a managed care healthcare setting.
• Active unrestricted RN license to practice in applicable state(s).
• AS or BS in Nursing preferred.
• Strong oral, written and interpersonal communication skills, problem-solving, facilitation and analytical skills.
• Proficient computer skills; familiar with FACETS is helpful but not required.
• Schedule: M-F 8:30-5:30 (1 hour lunch, 2x15 min breaks).
• 100% remote; Maryland license required.
• Candidates live within 50 miles of an Elevance Health PulsePoint.

Responsibilities

• Investigate and process medical necessity appeals from members and providers.
• Review provider initial ER reviews and prospective/inpatient/retrospective records.
• Extrapolate and summarize medical information for medical director/consultants.
• Prepare recommendations to uphold or deny appeals for medical director approval.
• Ensure timely resolution to regulatory timeframes.
• Document and log appeal information on tracking systems.
• Generate written correspondence to providers, members, and regulators.
• Serve as SME for appeals/grievances/quality of care issues.

Skills

Oral communication

Written communication

Interpersonal skills

Problem-solving

Facilitation skills

Analytical skills

FACETS

Education

HS Diploma or equivalent

AS or BS in Nursing

Active RN license

Tools

FACETS

Job description

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 provider initial ER reviews and/or 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.

Will work remotely to assist team with ER REVIEWS: Responsible for investigating and processing and medical necessity requests from providers.

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.

Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Efficient in computer apps, fast learner. familiar with use of FACETS is helpful but not required

M-F 8:30-5:30 (includes 1hour lunch and 2 15 min breaks).

100% remote. Must have Maryland License.

Candidates must live within 50 miles of an Elevance Health PulsePoint.

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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.).