Nurse Reviewer I (US) at Elevance Health

Cincinnati, Ohio, United States

Apply Now

Not SpecifiedCompensation

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

Full TimeJob Type

UnknownVisa

Healthcare, 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

Conducts preauthorization, out of network, and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical, and department guidelines
Collaborates 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
Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network
Notifies ordering physician or rendering service provider office of the preauthorization determination decision
Follows up to obtain additional clinical information
Ensures 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 GuidelinesHealthcare Provider CollaborationUtilization ReviewMedical Screening

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, providing maximum flexibility and autonomy. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered unless an accommodation is granted.

What are the required qualifications for the Nurse Reviewer I role?

The position requires an AS in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or a minimum of 1 year of prior utilization management, medical management, 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 Monday - Friday 9:30am – 6pm local time, with at least one weekend coverage (Sat & Sun 8am-12pm CST, with a comp day during the week).

What salary or compensation does this role offer?

This information is not specified in the job description.

What preferred skills or experiences are highlighted for this role?

Preferred qualifications include familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO.

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.

Land your dream remote job 3x faster with AI

Try Jobo Free