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.
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