Utilization Review Clinician - Appeals
WellSkySalary not specified
Full Time
Mid-level (3 to 4 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
- HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting (or equivalent combination of education and experience)
- Current active unrestricted RN license to practice as a health professional within the scope of licensure in Ohio (or applicable state/territory)
Responsibilities
- Investigate, process, and review medical necessity appeals requests from members and providers
- Manage State Fair Hearing and External Medical Review requests, supporting legal, management, and executive leadership
- Conduct thorough investigations and reviews of appeals in preparation for litigation, acting as a resource for clinical and non-clinical teams
- Document and log appeal information in relevant tracking systems
- Generate written correspondence with members, providers, and regulatory entities
- Serve as a subject matter expert for appeals, grievances, and quality of care issues
- Act as a liaison with internal and external attorneys on regulatory cases, including accurate entry, investigation, and analysis of state appeals
- Summarize medical information for review by medical directors and consultants
- Prepare recommendations to uphold or deny appeals
- Ensure all grievance processes are completed within regulatory timeframes
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
What is the work arrangement for this Nurse Appeals role?
This is a hybrid position requiring associates to be in-office 1-2 days per week, with candidates required to be residents of Ohio and within a reasonable commuting distance from the posting location.
What are the minimum requirements for this position?
Candidates need a HS diploma or equivalent with at least 2 years of experience in a managed care healthcare setting, or equivalent combination, and a current active unrestricted RN license in Ohio.
What preferred skills are highlighted for this role?
Preferred qualifications include an AS or BS in Nursing, background in litigation or paralegal experience, understanding of grievance and appeals processes, knowledge of Medicare and Medicaid guidelines, proficiency in Microsoft Suite, and strong communication skills.
What is the schedule for this Nurse Appeals position?
The schedule is Monday through Friday, 8:00 AM to 5:00 PM Eastern Time, with some flexibility required depending on court hearing schedules.
What experience makes a strong candidate for this Nurse Appeals role?
Strong candidates will have an active RN license, managed care experience, and preferably a nursing degree along with exposure to litigation, appeals processes, Medicare/Medicaid guidelines, and excellent communication skills.
Elevance Health
Integrated health services and digital platform
About Elevance Health
Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.
Indianapolis, IndianaHeadquarters
1944Year Founded
$309.4MTotal Funding
IPOCompany Stage
Enterprise Software, Social Impact, HealthcareIndustries
10,001+Employees