Additional Information
Anticipated End Date:
2026-06-19
Position Title:
Nurse Appeals (US)
Job Description:
Nurse Appeals- Licensed Nurse
Location: Mason, OH; Cincinnati OH; Indianapolis, IN; Louisville, KY; Norfolk, VA and Richmond, VA
Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
Hours: The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers.
How you will make an impact:
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 a HS diploma or equivalent and a 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 Skills, Capabilities and Experiences:
AS or BS in Nursing preferred.
Three to five years of clinical experience as a Registered Nurse strongly preferred.
Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
Experience with Facets, Macess, and ACMP is preferred.
Job Level:
Non-Management Exempt
Workshift:
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.
Elevance Health (anthem) · Mason, 4361 Irwin Simpson Rd, OH