Appeals Nurse

Evolent • Springfield, IL • 6d ago

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You'll Be Doing:

The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve.

Collaboration Opportunities:

The Specialty Appeal nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments.

What You Will Be Doing:

Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures.

Documents communications with medical office staff and/or MD provider as required.

Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews.

Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes.

Refers cases to appropriate internal reviewers according to the business needs of the particular health plan.

Reviews requests for Urgent appeals compared to expedited criteria for downgrade to Standard processing, documenting accordingly.

Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals.

Other duties as assigned.

Qualifications Required and Preferred:

1-3 years' experience and as an RN - Required

Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment- Required

Able to work in a rotation to work 10:30am to 7pm CST (which includes 30-minute unpaid lunch break) 3 days/week, to meet the business needs of nurses providing coverage until 7:00pm CST. - Required

Must be able to exercise independent and sound judgment in clinical decision making. - Preferred

Able to navigate through internal and external computer systems. Working knowledge of Microsoft Office Product Suit - Preferred

Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities. - Preferred

Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally, including strong written and verbal communication skills. - Preferred

To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration.

Technical Requirements:

We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance.

The expected base salary/wage range for this position is $37- $42/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.

Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!

Hospital & Medical

Become a part of our caring community and help us put health first The Pre-Authorization Nurse 2 reviews prior authorization requests for appropriate care and setting, following guidelines and policies, and approves serv...

3d ago

Go to Apply

Registered Nurse II

Illinois Department of Human Services • Springfield, IL • 4d ago

Hospital & Medical

This job was posted by https://illinoisjoblink.illinois.gov : For more information, please see: https://illinoisjoblink.illinois.gov/jobs/13036047 **To be considered, applicants must apply through our official website: J...

4d ago

Go to Apply

Physical Therapist PT Home Health PRN

Elara Caring • Springfield, IL • 1w ago

Hospital & Medical

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join ou...

1w ago

Go to Apply

Lead Health Information Specialist

Datavant • Springfield, IL • 1w ago

Hospital & Medical

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format. Our platform is power...

1w ago

Go to Apply

Licensed Practical Nurse

Mary Bryant Home for the Blind • Springfield, IL • 1w ago

Hospital & Medical

This job was posted by https://illinoisjoblink.illinois.gov : For more information, please see: https://illinoisjoblink.illinois.gov/jobs/13028633 We are looking for a Licensed Practical Nurse to join our team. The ideal...

1w ago

Go to Apply

Principal Technical Program Manager - Health Operations

Oracle • Springfield, IL • 1w ago

Hospital & Medical

Job Description Oracle Health Data Intelligence (HDI) is hiring a Principal Technical Program Manager - Operations to lead key strategic and operational initiatives across the organization. This is a highly visible role...

1w ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.