Nurse Appeals - Medicare

Elevance Health; Norfolk (VA); Remote; USD 65,000 - 85,000; Full time

Job summary

Elevance Health is seeking a Nurse Appeals - Medicare to work virtually while ensuring efficient processing of medical necessity appeals. The candidate will conduct thorough investigations, evaluate medical records, and provide recommendations based on findings. A dedicated RN with a minimum of two years in managed care is preferred, making this a pivotal role in improving healthcare outcomes.

Benefits

Paid Time Off

Medical, Dental, and Vision benefits

401(k) + match

Incentive bonus programs

Qualifications

• Requires current active unrestricted RN license to practice.
• Minimum of 2 years' experience in a managed care healthcare setting.
• Understanding of Medicare regulatory guidelines preferred.

Responsibilities

• Investigates and processes medical necessity appeal requests.
• Reviews medical records of denied services for medical necessity.
• Documents appeals and generates correspondence with providers.

Skills

Critical assessment skills

Interpersonal communication

Problem-solving

Analytical skills

Education

HS diploma or equivalent

Bachelor's degree in Nursing (preferred)

Job description

Anticipated End Date:

2025-06-27

Position Title:

Nurse Appeals - Medicare

Job Description:

Nurse Appeals - Medicare

Location:

Virtual: This role enables associates to work virtually full-time, with the exception of 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.

Shift: The team rotates to cover Saturdays and holidays, leading to some shifts from Tuesday to Saturday and coverage on certain holidays.

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

How you will make an impact:

• 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.

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:

• Bachelor degree in Nursing preferred.

• Possesses strong critical assessment skills to interpret complex guidelines and apply them across all Medicare service reviews, preferred.

• Possesses understanding of Medicare regulatory guidelines, including Medicare-Medicaid integrated plans, or demonstrates the critical thinking skills to quickly acquire this understanding, preferred.

• Medicare review experience, 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 Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

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 may contact [e-mail] for assistance. 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.