RN Nurse Appeals Specialist - Managed Care

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