Nurse Appeals-RN (California)

Job Title Nurse Appeals-RN (California) Location & Remote Work Locations: Woodland Hills, CA and Costa Mesa, CA. This role is available for associates to work virtually full‑time, except for required in‑person training sessions. Responsibilities Investigate and process medical necessity appeal requests from members and providers. Review prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolate and summarize medical information for medical director, consultants, and other external review. Prepare recommendations to either uphold or deny appeal and forward to Medical Director for approval. Ensure that appeals and grievances are resolved in a timely manner to meet regulatory timeframes. Document and log appeal/grievance information on relevant tracking systems and mainframe systems. Generate written correspondence to providers, members, and regulatory entities. Utilize leadership skills and serve as a subject matter expert for appeals/grievances/quality of care issues, and act as a resource for clinical and non‑clinical team members in expediting the resolution of outstanding issues. Minimum Requirements High school diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting, or an equivalent combination of education and experience. 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. Preferred Skills, Capabilities, and Experiences AS or BS in Nursing. Strong computer and Microsoft skills. Experience managing member grievances. Quality of Care review experience. Case management review experience. Compensation & Benefits Salary range: $38.17 to $57.25. Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, 401(k) contribution, and many additional benefits subject to eligibility requirements. Equal Employment Opportunity Elevance Health is an equal employment opportunity employer. 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state (including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act) and local laws, and applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form and a member of the team will be in contact. #J-18808-Ljbffr The Elevance Health Companies, Inc.