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Nurse Appeals Jobs
Company | Elevance Health |
Address | Richmond, VA, United States |
Employment type | FULL_TIME |
Salary | |
Category | Hospitals and Health Care |
Expires | 2023-07-25 |
Posted at | 11 months ago |
- Job Family: Medical and Clinical
- Date Posted:Jun 23, 2023
- Req #: JR74829
- Type: Full time
- Florida, Florida
- Ohio, Ohio
- Virginia, Virginia
- New York, New York
- OH, CINCINNATI
- 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.
- Extrapolates and summarizes medical information for medical director, consultants and other external review.
- Utilizes 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.
- Conducts investigations and reviews of member and provider medical necessity appeals.
- Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
- Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
- Generates written correspondence to providers, members, and regulatory entities.
- 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 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.
- AS or BS in Nursing preferred.
- Managed care experience preferred.
- Appeals experience preferred.
- 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.
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