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Nurse Appeals Sr - California

Location:

  • CA, Woodland Hills

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Description

The Nurse Appeals Sr is responsible for investigating and processing the most complex grievances and appeals requests from members and providers.

*Ideal candidate will live on the West Coast. (California)

How you will make an impact:

  • Conduct investigations and reviews of member and provider grievances and 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 forwards 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 appropriate written correspondence to providers, members, and regulatory entities.
  • Serve as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.

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.

Minimum of 4 years of experience in Utilization Management or Appeals; or any combination of education and experience, which would provide an equivalent background.

Associate must be willing to cover an occasional Saturday and holiday shift to meet the business needs.

Associate must be willing to travel to closest pulse point to meet the hybrid flex work model as directed by manager. ( Could be 1x per quarter).

Preferred Skills and assets:

Milliman

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.


Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

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 leaders at all levels of the organization 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?

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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. 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. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

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