Nurse Reviewer I at Elevance Health

Chicago, Illinois, United States

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Not SpecifiedCompensation

Entry Level & New Grad, Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience, or any combination of education and experience which would provide an equivalent background
Current unrestricted RN license in applicable state(s)

Responsibilities

Conduct preauthorization, out of network, and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical, and department guidelines
Collaborate with healthcare providers and members to promote the most appropriate, highest quality, and effective use of diagnostic imaging to ensure quality member outcomes and optimize member benefits
Work on routine reviews with limited or no previous medical review experience, requiring guidance from more senior colleagues and/or management
Partner with more senior colleagues to complete non-routine reviews
Conduct initial medical necessity clinical screening and determine if initial clinical information meets medical necessity criteria or requires additional review
Conduct initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network
Notify ordering physician or rendering service provider office of the preauthorization determination decision
Follow up to obtain additional clinical information
Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics

Skills

Key technologies and capabilities for this role

NursingMedical Necessity ReviewPreauthorizationDiagnostic ImagingClinical ScreeningHealthcare Guidelines

Questions & Answers

Common questions about this position

Is this a remote position?

This role enables associates to work virtually full-time, with the exception of required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office, and candidates not within a reasonable commuting distance from the posting location(s) will not be considered unless an accommodation is granted.

What are the minimum requirements for this role?

Minimum requirements include an AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience, or equivalent. A current unrestricted RN license in applicable state(s) is required.

What is the work schedule for this position?

The schedule is 9:30am-6:00pm local time, with rotating weekends.

What preferred skills are mentioned for this role?

Preferred skills include familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans.

Are new graduates encouraged to apply for this position?

Yes, new grads are encouraged to apply.

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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