Nurse Appeals RN-Quality of Care

Elevance Health; Indianapolis (IN); Hybrid; USD 60,000 - 80,000; Full time

Benefits offered by this job

Merit increases

Paid Time Off

401(k) with match

Wellness programs

Job summary

A healthcare company is seeking a Nurse Appeals specialist to investigate and process medical necessity appeals from members and providers. The role involves reviewing grievances, preparing summaries for Quality of Care cases, and ensuring timely resolution of grievances. Applicants need a high school diploma or equivalent with at least 2 years of experience in a managed care setting, along with a current RN license. This position offers a hybrid work model and a range of competitive benefits.

Qualifications

• Minimum of 2 years experience in managed care healthcare setting.
• Current active unrestricted RN license in applicable state.

Responsibilities

• Conduct investigations and reviews of member grievances.
• Review medical records for grievance concerns.
• Document grievance information on relevant tracking systems.

Skills

Investigation skills

Detail-oriented

Leadership skills

Education

HS diploma or equivalent

AS or BS in Nursing (preferred)

Job description

Overview

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.

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

How you will make an impact:

Primary duties may include, but are not limited to:

• Conduct investigations and reviews of member grievances and Quality of Care cases.
• Review medical records for member grievance concerns and Quality of Care cases.
• Extrapolate and summarize medical information for medical director.
• Prepare nurse summaries for Quality of Care cases and forward to Medical Director for review and determination.
• Ensure grievances are resolved timely to meet regulatory timeframes.
• Document and log grievance information on relevant tracking systems and mainframe systems.
• Generate written correspondence to providers, members, and regulatory entities.
• Utilize leadership skills and serve as a subject matter expert for grievances/quality of care issues and be a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

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.
• Multi-state/compact RN license 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 may contact [e-mail] 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