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Grievances and Appeals - RN at Evolent Health

Grievances and Appeals - RN

Evolent Health Santa Fe, NM Full-Time
**Your Future Evolves Here**

Evolent Health has 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. We have fun while working hard and Evolenteers often make a difference _working_ in everything from scrubs to jeans.

Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as "Great Places to Work" in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation's Corporate Equality Index (CEI). This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.

We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you're looking for a place where your work can be personally and professionally rewarding, don't just join a company with a mission. Join a mission with a company behind it.

**What You'll Be Doing:**

**What You'll Be Doing:**

+ Act as a member advocate addressing member or provider concerns

+ Evaluate, 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 fortitude 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

**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 objectively

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

**Finishing Touches (Preferred):**

+ BS Degree or equivalent work experience

+ Expertise in Medicare appeals

+ Medical coding experience

**Mandatory Requirements:**

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 Mbps, 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.

**Preferred Requirements:**

Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and national law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home.

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**Evolent Health 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** .

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