Nurse Appeals – Litigation & Legal Support

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Job Description:

Nurse Appeals Litigation & Legal Support

Location: North Carolina candidates must be residents of North Carolina to be considered.

In Office Expectation: This role is 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.

Schedule:Monday Friday 8:00AM 5:00PM Eastern Time;some flexibility in hours will be necessary and is dependent on court hearing schedules.

The Nurse Appeals Litigation & Legal Supportis 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:

• Supports legal management and executive leadership by managing State Fair Hearing and External Medical Review requests.

• Acts as a resource for both clinical and non-clinical teams by managing and conducting thorough investigations and reviews of medical necessity appeals from members and providers in preparation litigation.

• Documenting and logging appeal information in relevant tracking systems generating written correspondence with members providers and regulatory entities and serves as a subject matter expert for appeals grievances and quality of care issues.

• Key responsibilities: serves as a liaise with internal and external attorneys on regulatory cases including ensuring accurate entry investigation and analysis of state appeals; summarizing medical information for review by medical directors and consultants; preparing recommendations to uphold or deny appeals; and ensuring all grievance processes are completed within regulatory timeframes.

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 & Experiences:

• AS or BS in Nursing preferred.

• Background or exposure in litigation legal proceedings and/or paralegal experience is strongly desired.

• Understanding of the grievance and appeals process is strongly preferred.

• Basic knowledge of Medicare and Medicaid guidelines is preferred.

• Ability to and comfortability working with: internal and external legal counsel medical directors judges and other management/leadership as necessary.

• Proficiency in Microsoft Suite Products (e.g. Outlook Excel and Word).

• Associates in this role are expected to have strong oral written and interpersonal communication skills with an ability to problem-solve organize and execute tasks with minimal supervision.

For URAC accredited areas the following professional competencies apply: Associates in this role are expected to have strong oral written and interpersonal communication skills problem-solving skills facilitation skills and analytical skills.

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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 local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age citizenship status color creed disability ethnicity genetic information gender (including gender identity and gender expression) marital status national origin race religion sex sexual orientation veteran status or any other status or condition protected by applicable federal state or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.