Nurse Appeals Specialist
2 weeks ago
This position will work a hybrid model (remote and office) and requires candidates to reside in Olathe, KS, Topeka, KS, or Overland Park, KS.
Key Responsibilities- Conduct investigations and reviews of member and provider medical necessity appeals.
- Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
- Extrapolate and summarize medical information for medical director, consultants, and other external review.
- Prepare recommendations to either uphold or deny appeal and forward to Medical Director for approval.
- Ensure that appeals and grievances are resolved timely to meet regulatory timeframes.
- Document and log appeal/grievance information on relevant tracking systems and mainframe systems.
- Generate written correspondence to providers, members, and regulatory entities.
- 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.
- AS or BS in Nursing preferred.
- Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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.
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.
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. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws.
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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