Nurse Appeals (Contract) Jobs

Job ID:JP43563

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for contract workers (via BCforward) who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to 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.
• Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
• Utilize 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.
• Extrapolates and summarizes medical information for medical director, consultants and other external review.
• Generates written correspondence to providers, members, and regulatory entities.
• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
• Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.

Requirements:

• 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.
• Requires 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.

Preferred

• AS/BS in Nursing preferred

Additional Details

• Monday-Friday 8am-5pm
• Remote

BCForward is An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.

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