Nurse Appeals Management Specialist

Your Future Evolves Here Evolent is a pioneering force in partnering with health plans and providers to achieve outstanding outcomes for individuals navigating complex health challenges. Our commitment is to bridge the gaps in the fragmented healthcare system, ensuring that everyone receives the compassionate care they deserve. At Evolent, we prioritize work/life balance and foster flexibility, allowing our employees to seamlessly integrate their professional and personal lives. We encourage an environment of autonomy where everyone can thrive and be their authentic selves. Our dedication to diversity and inclusion is fundamental to our mission. Join our team at Evolent and be part of our mission. Stay for our inclusive culture. Key Responsibilities: Become a vital member of the Specialty Appeals Team, where you’ll have the chance to significantly impact a dedicated group focused on appeals and post-determination requests. You will adhere to Evolent and Client policies and procedures, ensuring compliance with utilization management principles and timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, which are essential in driving improvements in health outcomes for our clients and members. Collaboration Opportunities: As an Appeals Nurse, you will work closely within a dedicated team to carry out comprehensive reviews of appeal requests for designated clients. This includes coordinating appeals with team members, consulting with Physicians and other Clinicians for evaluations, and seeking guidance from management. Teamwork is highly valued, supported through regular meetings, digital communication, and monthly updates on performance metrics and accomplishments. What You Will Do: Adhere to utilization management and appeals management principles while following company policies and procedures. Document communications with medical office staff and/or MD providers as necessary. Effectively coordinate with other departments to resolve issues related to appeals and retrospective reviews. Provide exceptional customer service through professional and effective communication, meeting accreditation and health plan requirements. Refer cases to appropriate internal reviewers based on business needs. Evaluate urgent appeal requests against expedited criteria, documenting findings as necessary. Collaborate closely with clinical reviewers to ensure timely processing of appeals. Perform additional duties as assigned. Qualifications Required and Preferred: 1-3 years of RN experience - Required Minimum of 5 years in Utilization Management or healthcare appeals, compliance, or grievances/complaints in a quality improvement setting - Required Availability to work a rotating schedule from 10:30 AM to 7:00 PM CST, including a 30-minute unpaid lunch break - Required Ability to demonstrate independent and sound clinical judgment - Preferred Proficient in navigating internal and external computer systems with working knowledge of Microsoft Office Suite - Preferred Strong organizational and time management abilities with a proven ability to manage multiple priorities effectively - Preferred Excellent interpersonal and negotiation skills along with strong written and verbal communication skills - Preferred To ensure a secure hiring process, we have implemented several identity verification steps, including the submission of a government-issued photo ID. Identity verification will take place 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 before employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Technical Requirements: All employees must have high-speed internet of at least 10 Mbps, and for all call center roles, a direct connection to the home internet router. These at-home technical requirements may change depending on the reopening of our office locations. Evolent is an equal opportunity employer, welcoming all qualified applicants fairly, regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you require reasonable accommodation to access information on this website, please reach out for assistance. The expected base salary for this position is $37 - $42 per hour. This role is also eligible for a bonus based on predefined performance factors. Evolent proudly offers comprehensive benefits, including health insurance, to qualifying employees as part of our total compensation package. Salary determinations are based on the skills and experience needed for the position and may vary based on the qualifications of selected candidates. If you don’t see your dream job, please submit your contact information along with your resume, and we will reach out if we identify a perfect match!

Created: 2026-03-04