Nurse Appeals Specialist

4 days ago


Palo Alto, California, United States Elevance Health Full time
Job Summary

We are seeking a skilled Nurse Appeals Specialist to join our team at Elevance Health. As a key member of our quality of care team, you will be responsible for investigating and processing quality of care grievances from members and providers.

Key Responsibilities
  • Conduct thorough investigations and reviews of member and provider quality concerns.
  • Review prospective, inpatient, or retrospective medical records to identify areas for improvement.
  • Extrapolate and summarize medical information for medical directors, consultants, and other external reviewers.
  • Prepare recommendations for assigning appropriate levels of care or forward to medical directors for decision-making.
  • Ensure timely resolution of grievances to meet regulatory requirements.
  • Document and log appeal/grievance information on relevant tracking systems and mainframe systems.
  • Generate written correspondence to providers, members, and regulatory entities.
  • Utilize leadership skills and serve as a subject matter expert for appeals/grievances/quality of care issues, providing guidance to clinical and non-clinical team members.
Requirements
  • Minimum of 2 years of experience in a managed care healthcare setting or equivalent combination of education and experience.
  • Current active unrestricted RN license from the State of California required.
  • Preferred qualifications include ER experience, appeals/quality of care experience, managed care experience, and AS or BS in Nursing.
What We Offer

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution. We are 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.



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