Nurse Appeals Lead (RN)

Anticipated End Date:

2025-06-18

Position Title:

Nurse Appeals Lead (RN)

Job Description:

Nurse Appeals Lead (RN)

Location: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of remote work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

Shift: Monday to Friday from 8:00am-5:00pm PST

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.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $86,480 to $155,664

Locations: California

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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 co