Nurse Appeals (Grievance & Appeals)

Anticipated End Date:

2025-12-26

Position Title:

Nurse Appeals (Grievance & Appeals)

Job Description:

Nurse Appeals –Licensed Nurse   

Location: Ohio, candidates must be residents of Ohio to be considered. 

Hybrid 1: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

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.

Schedule: Monday – Friday, 8:00AM – 5:00PM Eastern Time; some flexibility in hours will be necessary and is dependent on court hearing schedules.  

The Nurse Appeals is responsible for investigating and processing and medical necessity appeals requests from members and providers. 

How You Will Make an Impact:
·Supports legal, management, and executive leadership by managing State Fair Hearing and External Medical Review requests.

·Acts as a resource for both clinical and non-clinical teams, by managing and conducting thorough investigations and reviews of medical necessity appeals from members and providers in preparation litigation.

·Documenting and logging appeal information in relevant tracking systems, generating written correspondence with members, providers, and regulatory entities, and serves as a subject matter expert for appeals, grievances, and quality of care issues.

·Key responsibilities: serves as a liaise with internal and external attorneys on regulatory cases, including ensuring accurate entry, investigation, and analysis of state appeals; summarizing medical information for review by medical directors and consultants; preparing recommendations to uphold or deny appeals; and ensuring all grievance processes are completed within regulatory timeframes.

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, & Experiences:

·AS or BS in Nursing preferred.

·Background or exposure in litigation, legal proceedings, and/or paralegal experience is strongly desired.

·Understanding of the grievance and appeals process is strongly preferred.

·Basic knowledge of Medicare and Medicaid guidelines is preferred.

·Proficiency in Microsoft Suite Products (e.g. Outlook, Excel, and Word).

·Associates in this role are expected to have strong oral, written, and interpersonal communication skills, with an ability to problem-solve, organize, and execute tasks with minimal supervision.

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.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $66,640 to $99,960.

Locations: Cleveland, OH & Columbus, OH

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, paid time off, stock, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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.

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.

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.