Nurse Appeals (RN) CA

$65,125 - $117,229/Yr

Elevance Health - Los Angeles, CA

Full-time - Entry Level

Los Angeles, CA

11-50 employees

Insurance Carriers and Related Activities

About the position

The Nurse Appeals position is a hybrid role responsible for investigating and processing medical necessity appeals requests from members and providers. The role involves reviewing medical records, summarizing medical information, preparing recommendations for appeals, and ensuring timely resolution of grievances. The ideal candidate will have a strong background in managed care healthcare settings and possess excellent communication and analytical skills.

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 reviews.
• Prepare recommendations to either uphold or deny appeals 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.
• Utilize leadership skills and serve as a subject matter expert for appeals/grievances/quality of care issues.

Requirements

• Minimum of 2 years of experience in a managed care healthcare setting.
• 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.

Nice-to-haves

• AS or BS in Nursing preferred.
• Strong oral, written, and interpersonal communication skills.
• Problem-solving skills, facilitation skills, and analytical skills.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid holidays
• Paid Time Off
• Medical, dental, vision benefits
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources