Nurse Appeals (RN) CA
$65,125 - $117,229/Yr
Elevance Health - Los Angeles, CA
posted 2 months ago
Full-time - Mid Level
Los Angeles, CA
11-50 employees
Insurance Carriers and Related Activities
About the position
The Nurse Appeals (RN) position at Elevance Health involves investigating and processing medical necessity appeals requests from members and providers. The role requires conducting thorough reviews of medical records, preparing recommendations for appeals, and ensuring timely resolution of grievances in compliance with regulatory standards. This position operates in a hybrid model, requiring candidates to reside within 50 miles of a PulsePoint location in California.
Responsibilities
- Investigate and process medical necessity appeals requests from members and providers.
- Review prospective, inpatient, or retrospective medical records of denied services for medical necessity.
- Summarize medical information for medical director and external reviews.
- Prepare recommendations to uphold or deny appeals and forward to Medical Director for approval.
- Ensure timely resolution of appeals and grievances to meet regulatory timeframes.
- Document and log appeal/grievance information on relevant tracking systems.
- Generate written correspondence to providers, members, and regulatory entities.
- Serve as a subject matter expert for appeals/grievances and quality of care issues.
Requirements
- Current active unrestricted RN license to practice in California.
- Minimum of 2 years of experience in a managed care healthcare setting.
- Bachelor's degree in Nursing preferred.
- Strong oral, written, and interpersonal communication skills.
- Problem-solving and analytical skills.
Nice-to-haves
- Associate's degree in Nursing.
- Leadership experience.
Benefits
- Employee stock purchase plan
- Paid holidays
- Disability insurance
- Health insurance
- Dental insurance
- 401(k)
- Paid time off
- Vision insurance
- 401(k) matching
- Life insurance
