What are the responsibilities and job description for the Nurse Appeals Associate II position at The Elevance Health Companies, Inc.?
Anticipated End Date: 2025-04-28 Position Title: Nurse Appeals Associate II Job Description: Nurse Appeals Associate II Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health Pulse Point locations. The Nurse Appeals Associate II is responsible for supporting the development and implementation of quality improvement interventions and audits. Responsible for more complex, sensitive and specialized medical necessity and administrative appeals cases such as NICU, transgender, transplants, high level surgeries, cardiac. How you will make an impact: Primary duties may include, but are not limited to: Researches, collects data, and submits and resolves medical necessity and administrative appeals. Researches and analyzes case and compares to medical guidelines, medical policy and requirements. Prepares clinical grievances for medical director review. Works with Medical Director on case resolution. Gathers and validates information for reports, audits and reviews. Contributes to external reviews site visit preparations by the State, accreditation review and Quality Management Committee; conducts internal monitoring and audits timeline compliance standards. Ensures case files are accurate to aid in the investigation of cases. Processes, tracks, trends, and reports complaint and grievances issues. Prepares complaint and grievance files for Fair Hearings and serves as a subject matter expert on complaints and grievances for non-clinical staff. Participates in quarterly Plan HIPAA audits. Minimum Requirements: Requires an LVN/LPN and minimum of 3 years of related experience in healthcare, insurance, grievance & appeals or managed care and minimum of 1-year clinical experience; or any combination of education and experience, which would require an equivalent background. Current unrestricted LPN/LVN license in applicable state(s) required. Preferred Skills, Capabilities and Experiences: Medicare knowledge preferred. Experience with Appeals or Utilization Management, and denials preferred. CMS Regulations and guidelines knowledge preferred. Job Level: Non-Management Non-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 and Influenza. 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 elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. 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. Join our Talent Community and stay connected with company news, information, and future job opportunities. Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner. Our nearly 100,000 associates serve approximately 100M people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health. Please visit the Contract Worker Community Page. Elevance Health is an Equal Opportunity Employer/Disability/Veterans.
