Elevance Health • Walnut Creek, CA 94597
Job #2695829602
Nurse Appeals- California candidates only
Location: This is a virtual position and prefer candidates reside within 50 miles of an Elevance Health PulsePoint location.
Schedule: Monday - Friday 8:00 am to 4:30 pm PST Saturdays and Holidays required
How you will 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.
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.
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.
Minimum Requirements:
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.
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 Capabilities, Skills and Experiences:
UM experience preferred
Appeals experience preferred
Managed Care experience preferred
AS or BS in Nursing preferred
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For candidates working in person or remotely in the below locations, the hourly* range for this specific position is $36.01 to $59.18 an hour.
Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully 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 .
Elevance Health • Walnut Creek, CA 94597 • Yesterday
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