Nurse Appeals - Litigation & Legal

Nurse Appeals - Litigation & Legal Support

2 days ago | Be among the first 25 applicants.

This range is provided by Elevance Health. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

$69,972.00/yr - $/yr

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 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.

Monday - Friday, 9:00 AM - 6:00 PM in your time zone; some flexibility in hours will be necessary and is dependent on court hearing schedules.

The Nurse Appeals - Litigation & Legal Support is responsible for investigating and processing medical necessity appeals requests from members and providers.

• 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 for litigation.
• Documents and logs appeal information in relevant tracking systems, generates written correspondence with members, providers, and regulatory entities, and serves as a subject matter expert for appeals, grievances, and quality of care issues.
• Serves as a liaison with internal and external attorneys on regulatory cases, ensuring accurate entry, investigation, and analysis of state appeals; summarizes medical information for review by medical directors and consultants; prepares recommendations to uphold or deny appeals; and ensures all grievance processes are completed within regulatory time frames.

• High school diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting, or any combination of education and experience that provides 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.

• AS or BS in Nursing preferred.
• Background or exposure in litigation, legal proceedings, and/or paralegal experience strongly desired.
• Understanding of the grievance and appeals process strongly preferred.
• Basic knowledge of Medicare and Medicaid guidelines preferred.
• Ability, and comfort, working with internal and external legal counsel, medical directors, judges, and other management/leadership as necessary.
• Proficiency in Microsoft Office (Outlook, Excel, Word).
• Strong oral, written, and interpersonal communication skills; problem‑solving, organizational, and execution skills with minimal supervision.

New York

Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase plan, and 401(k) contributions.

Elevance Health is an Equal Employment Opportunity employer. All qualified applicants will receive consideration without regard to age, citizenship status, color, creed, disability, ethnicity, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthj for assistance.

Qualified applicants with arrest or conviction records will be considered in accordance with all federal, state, and local laws.