Nurse Appeals Specialist

5 days ago

Topeka, Kansas, United States Elevance Health Full time

Nurse Appeals Role Overview

The Nurse Appeals role at Elevance Health is responsible for investigating and processing medical necessity appeals requests from members and providers. This position requires a strong understanding of healthcare regulations and policies, as well as excellent communication and analytical skills.

Key Responsibilities:

  • 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.

Requirements:

  • 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:

  • AS or BS in Nursing preferred.
  • Strong oral, written, and interpersonal communication skills.
  • Problem-solving skills, facilitation skills, and analytical skills.

About Elevance Health:

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.

Our Culture:

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.

Hybrid Workforce Strategy:

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.

Equal Employment Opportunity:

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.

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