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Nurse Reviewer I

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Elevance Health

9d ago

  • Job
    Full-time
    Mid Level
  • Customer Relations
    Healthcare
  • Las Vegas
    Remote

AI generated summary

  • You need an AS in nursing, 3 years clinical experience or 1 year in utilization management, an unrestricted RN license, and familiarity with UM guidelines and coding. BA/BS preferred.
  • You will collaborate with providers on diagnostic imaging, conduct medical necessity reviews, assess preauthorization requests, communicate decisions, and ensure proper documentation and follow-up.

Requirements

  • 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.
  • A current unrestricted RN license in applicable state(s) required.
  • Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO and POS plans strongly preferred.
  • BA/BS degree preferred.
  • Previous utilization and/or quality management and/or call center experience preferred.

Responsibilities

  • 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 to optimize member benefits.
  • Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management.
  • Partners with more senior colleagues to complete non-routine reviews.
  • Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.
  • 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.
  • Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics.

FAQs

What is the work schedule for the Nurse Reviewer I position?

The work schedule is Monday to Friday, 9:30 AM - 6:00 PM CST/PST.

Is the Nurse Reviewer I position fully remote?

This role enables associates to work virtually full-time, with the exception of required in-person training sessions.

What are the minimum requirements for this position?

The minimum requirements include an Associate's degree in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or 1 year of prior utilization management, medical management, or quality management experience, along with a current unrestricted RN license.

Are there any preferred qualifications for applicants?

Yes, preferred qualifications include familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, as well as previous experience in utilization management and/or quality management.

What is the salary range for the Nurse Reviewer I position?

The salary range for this specific position is $33.92 to $53.30, depending on various factors including location, work experience, education, and skill level.

Does Elevance Health offer benefits to employees?

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

Is there a requirement for COVID-19 vaccination for new hires?

Yes, all new candidates in certain patient/member-facing roles are required to become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided.

How does Elevance Health ensure equal employment opportunities?

Elevance Health is an Equal Employment Opportunity employer and considers all qualified applicants for employment without discrimination based on various protected statuses.

Can candidates from outside commuting distance apply for this position?

Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment unless an accommodation is granted as required by law.

What will a Nurse Reviewer I do in this role?

A Nurse Reviewer I is responsible for conducting preauthorization reviews for diagnostic imaging services and collaborating with healthcare providers to ensure the appropriate use of these services.

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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.