Utilization Review Clinician - Appeals
WellSkySalary not specified
Full Time
Mid-level (3 to 4 years)
Not SpecifiedCompensation
Junior (1 to 2 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 any combination of education and experience providing 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
- Must be within commutable distance to listed locations (Ohio-Cincinnati, Columbus, Mason, or Seven Fields)
Responsibilities
- Conducts investigations and reviews of member and provider medical necessity appeals
- Reviews prospective, inpatient, 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
- Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
What is the salary range for the Nurse Appeals RN position?
For candidates working in Columbus, OH, the salary range is $66,640 to $99,960. The salary offered is based on legitimate, non-discriminatory factors.
Is this a remote position, and what are the location requirements?
This role enables associates to work virtually full-time, except for required in-person training sessions. Candidates must be within commutable distance to Cincinnati, Columbus, Mason, or Seven Fields, OH, and those not within reasonable commuting distance will not be considered unless an accommodation is granted.
What are the minimum requirements for this role?
Requires a 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. A current active unrestricted RN license in applicable state(s) is required.
What benefits does Elevance Health offer?
In addition to salary, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution, all subject to eligibility requirements.
What preferred qualifications will make my application stronger?
An AS or BS in Nursing is preferred, along with experience in managed care and appeals processing.
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
Benefits
Medical, dental, & vision insurance
401(k) + match
Paid holidays
Paid Time Off
Incentive bonus programs
Stock purchase plan
Life insurance
Wellness Programs
Financial education resources
Adoption & Surrogacy Assistance
Dependent-care Flexible Spending Account (DCFSA)
Parental Leave
Parental Transition Week
Critical Caregiving Leave
Risks
Departure of CFO John Gallina may create a gap in financial leadership.
Lawsuit against CMS over MA Star Ratings could lead to financial penalties.
CareBridge integration may face operational challenges, disrupting service delivery.
Differentiation
Elevance Health integrates whole health approach with digital health platform for comprehensive care.
Acquisition of CareBridge enhances home health services within Carelon division.
Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.
Upsides
AI integration in home health services can reduce hospital readmissions and improve outcomes.
Predictive analytics support early disease detection, aligning with Elevance's whole health approach.
Telehealth expansion offers opportunities to reach more patients remotely.
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