Nurse Appeals

Nurse Appeals (Quality) - California candidates only

Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health California PulsePoint locations listed on the requisition.

Schedule: Monday - Friday 8:00 am to 4:30 pm PST.

How you will make an impact:

Responsible for investigating and processing quality of care grievances from members and providers.

Primary duties may include, but are not limited to:

• Conducts investigations and reviews of member and provider quality concerns.

• Reviews prospective, inpatient, or retrospective medical records.

• Extrapolates and summarizes medical information for medical director, consultants and other external review.

• Prepares recommendations to assign appropriate level or forwards to Medical Director for decision.

• Ensures that 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 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 from the State of California required.

Preferred Capabilities, Skills and Experiences:

• ER experience preferred.

• Appeals/Quality of care experience preferred.

• Managed Care experience preferred.

• AS or BS in Nursing 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.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $34.44 to $58.71.

Locations: California

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. 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 .

• The salary range is the range Elevance Health 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. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.