Nurse Appeals Ca

2 weeks ago

Woodland Hills, United States Elevance Health Full time

Job Family: MED > Licensed Nurse
- Type: Full time
- Date Posted: Apr 24, 2024
- Anticipated End Date: May 01, 2024
- Reference: JR112445

**Description**:
**Nurse Appeals

**Schedule: Monday**:

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

The **Nurse Appeals **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.

**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.

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

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.

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