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Nurse Reviewer I

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Elevance Health

24d ago

  • Job
    Full-time
    Mid Level
  • People, HR & Administration
    Healthcare
  • Tampa

AI generated summary

  • You need an AS in nursing, 3 years of clinical experience or 1 year in utilization management. RN license required. Familiarity with UM guidelines, coding, and MS Office preferred.
  • You will assess medical necessity for preauthorization requests, communicate decisions to providers, follow up for additional information, and ensure documentation meets department standards.

Requirements

  • Minimum Qualifications
  • Requires 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) required.
  • Preferred Skills, Capabilities And Experiences
  • Familiarity with Utilization Management Guidelines is preferred
  • ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
  • BA/BS degree preferred.
  • Previous utilization and/or quality management and/or call center experience preferred.
  • Proficiency in Microsoft Office Products is strongly preferred

Responsibilities

  • 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.
  • Other duties as assigned.

FAQs

Do we support remote work?

Yes, this role allows for virtual full-time work, except for required in-person training sessions.

What are the work hours for the Nurse Reviewer I position?

The work hours are Monday to Friday from 11:30 AM to 8:00 PM Central, with rotating weekends from 8:00 AM to 12:00 PM.

What qualifications are required for this position?

A minimum of an Associate's degree in nursing and either 3 years of clinical nursing experience or 1 year of experience in utilization management, medical management, or quality management is required. A current unrestricted RN license in applicable state(s) is also needed.

Is prior experience in utilization management preferred?

Yes, prior utilization management, medical management, and/or quality management experience is strongly preferred.

What skills are preferred for applicants?

Familiarity with Utilization Management Guidelines, knowledge of ICD-9 and CPT-4 coding, and proficiency in Microsoft Office products are preferred.

What is the salary range for this position?

The salary range for this position is between $34.69 to $54.41 per hour, depending on various factors such as geographic location, work experience, and education.

Are there any vaccination requirements for this role?

Yes, candidates in patient/member-facing roles are required to be vaccinated against COVID-19 and Influenza, unless they provide an acceptable explanation.

Do we offer benefits to employees?

Yes, Elevance Health offers a comprehensive benefits package, including medical, dental, vision, 401(k) contributions, paid time off, and wellness programs, among others.

Is an in-person presence required for this position?

Yes, there will be required in-person training sessions, but the role primarily supports remote work.

Is there potential for salary modification in the future?

Yes, the salary range may be modified in the future, and actual compensation may vary based on market/business considerations and other factors.

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Elevance Health

Improving the health of humanity

Science & Healthcare
Industry
10,001+
Employees

Mission & Purpose

Fueled by our bold purpose to improve the health of humanity, we are transforming from a traditional health benefits organization into a lifetime trusted health partner.   Our nearly 100,000 associates serve more than 118 million people, at every stage of health. We address a full range of needs with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health.  We believe that improving health for everyone is possible. It begins by redefining health, reimagining the health system, and strengthening our communities.