Anticipated End Date:

2024-10-30

Position Title:

Nurse Appeals Lead-Medicaid Appeals

Job Description:

Nurse Appeals Lead-Medicaid Appeals

Location:  This position will work a hybrid model (remote and in office). The ideal candidate will live within 50 miles of one of the following Elevance Health PulsePoint locations:

• Topeka, Kansas
• Olathe, Kansas
• Mason, Ohio
• Norfolk, VA
• Atlanta, GA
• Tampa, FL

The Nurse Appeals Lead is responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers and provide leadership and work direction to other appeals staff.

How you will make an impact:

Primary duties may include, but are not limited to:

• Conducts investigations and reviews of member and provider grievances and appeals.
• Reviews prospective 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.
• Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 5 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
• Current active valid 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 Skills, Capabilities and Experiences:

• AS or BS in Nursing preferred.
• Medicaid Appeals knowledge 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.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 [email protected] for assistance.