Nurse Appeals-RN (California)
$79,286–$119,080 year
Hybrid · Costa Mesa, California, United States or Woodland Hills, California, United States
Job Summary
Nurse Appeals-RN role focusing on investigating and processing member and provider medical-necessity appeals. Responsibilities include reviewing prospective, inpatient, or retrospective medical records to determine medical necessity, extrapolating and summarizing information for medical directors and external reviewers, preparing recommendations to uphold or deny appeals, and ensuring timely resolution to regulatory timeframes. The role documents and logs appeal/grievance information in tracking/mainframe systems, generates written correspondence to providers and members, and serves as a subject-matter expert for appeals, grievances, and quality-of-care issues to expedite issue resolution. Preferred candidates have AS or BS in Nursing, strong computer skills, and experience with member grievances and quality-of-care or case-management reviews. The position operates within Elevance Health’s hybrid workforce strategy, with virtual work possible and required in-person trainings; location options include Woodland Hills, CA or Costa Mesa, CA. The posting notes a salary range of $38.17 to $57.25 per hour for in-scope locations, with benefits and equal opportunity employment details provided. The role requires licensure as a nurse in the applicable state(s) and is non-management/non-exempt in job level, under a non-specified shift pattern.
Required Qualifications
- HS diploma or equivalent
- Current active valid unrestricted RN license to practice within the scope of licensure in applicable state(s) or territory of the United States
- Minimum 2 years of experience in a managed care healthcare setting
- AS or BS in Nursing preferred (optional additional qualification)
- Strong computer skills (Microsoft) preferred
- Experience managing member grievances preferred
- Quality of Care review experience preferred
- Case management review experience preferred
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