Nurse Appeals RN-Quality of Care

Anticipated End Date:

2026-02-04

Position Title:

Nurse Appeals RN-Quality of Care

Job Description:

Nurse Appeals RN-Quality of Care

Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

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.

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

How you will make an impact:

Primary duties may include, but are not limited to:

• Conducts investigations and reviews of member grievances and Quality of Care cases.

• Reviews medical records for member grievance concerns and Quality of Care cases.

• Extrapolates and summarizes medical information for medical director

• Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination.

• Ensures  grievances are resolved timely to meet regulatory timeframes.

• Documents and logs 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 grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

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 and Experiences:

• AS or BS in Nursing preferred.

• Multi-state/compact RN license preferred.

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