Registered Nurse, Appeals & Grievances

Evolent Health, Inc. Louisville , KY 40202

Posted 2 months ago

We are seeking several nurses with Appeals & Grievances experience to join the team due to tremendous growth! We have a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins.

Come join us!

What You'll Be Doing:

  • Act as a member advocate addressing member or provider concerns

  • Analyze, review and evaluate appeals and grievances in compliance with state, federal and other regulatory requirements

  • Research, investigate and summarize complex issues using state and federally mandated benefits, EOC/COC/SPD benefit language, CMS guidelines, Medical Policies and Interqual criteria

  • Prepare cases for Medical Director and/or External Review

  • Develop timely and professional documentation and correspondence that ensures accuracy, completeness and conformance to quality and regulatory standards

  • Formulate determination language that resolves member or provider issues in a manner consistent with regulatory and accrediting agency requirements

  • Recognize potential quality of care concerns

  • Utilize multiple internal and external computer applications and programs

  • Meet established productivity and quality standards

  • Quarterly travel for team events and trainings

The Experience You Need (Required):

  • Active, unrestricted Registered Nurse license

  • Minimum of 2 years of appeals experience in a payer-based environment

  • Minimum of 5 years of acute care or outpatient clinical experience

  • Minimum of 3 years of utilization management experience in a payer-based environment

  • Excellent written and oral communication skills

  • Proficiency with PC-based software programs including Word, Excel and Outlook

  • Strong critical thinking, analytical, research and organizational skills

  • Ability to work remotely and independently

  • Access to high speed broadband or DSL internet in a secure home office

Finishing Touches (Preferred):

  • BS Degree

  • Expertise in Medicare appeals

  • Medical coding experience

  • Medical claims review experience

Evolent Health is an Equal Opportunity/Affirmative Action Employer

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Registered Nurse, Appeals & Grievances

Evolent Health, Inc.