Nurse Appeals-CA

4 weeks ago

PALO ALTO, United States Elevance Health Full time

Nurse Appeals- California candidates only

Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health PulsePoint location.

Schedule: Monday - Friday 8:00 am to 4:30 pm PST Saturdays and Holidays required

How you will make an impact:

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 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 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 Capabilities, Skills and Experiences:

  • UM experience preferred

  • Appeals 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 locations, the hourly* range for this specific position is $36.01 to $59.18 an hour.

Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

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

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