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Nurse Reviewer I

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Elevance Health

2mo ago

  • Job
    Full-time
    Mid Level
  • Customer Relations
    Healthcare
  • Los Angeles

AI generated summary

  • You need an AS in nursing with 3 years of clinical experience or 1 year in utilization management, plus an unrestricted RN license in the required state(s).
  • You will conduct preauthorization reviews for diagnostic imaging, assess medical necessity, collaborate with providers, notify decisions, and ensure documentation meets department standards.

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.
  • Current unrestricted RN license in applicable state(s) required.

Responsibilities

  • The Nurse Reviewer I will be responsible for conducting 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 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 request to assess assessing 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.
  • Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

FAQs

Do we support remote work?

Yes, this role is primarily virtual, allowing associates to work full-time remotely with the exception of required in-person training sessions.

What are the working hours for this position?

The work schedule is Monday to Friday from 9:30 am to 6 pm local time, with rotating weekends (Saturdays from 8 am to 12 pm CST and a compensatory day during the week).

What qualifications are required for the Nurse Reviewer I position?

A nursing degree (AS in nursing) and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting are required, or at least 1 year of prior utilization management or related experience.

Is a specific nursing license required for this position?

Yes, a current unrestricted RN license in the applicable state(s) is required.

Are there any preferred qualifications for this role?

Preferred qualifications include familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, managed care plans, and previous utilization and/or quality management or call center experience.

Is there a salary range for this position?

Yes, the salary range for this position is between $36.27 to $56.77 per hour, dependent on various factors such as geographic location and experience.

What benefits does Elevance Health offer?

Elevance Health offers a comprehensive benefits package which includes medical, dental, and vision coverage, paid time off, retirement plans, wellness programs, and financial education resources.

Do I need to be vaccinated against COVID-19 to apply?

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

Will there be opportunities for professional development?

Yes, Elevance Health offers a culture designed to advance personal and professional growth for associates through mentoring and skill development.

Can applicants with arrest or conviction records apply for this position?

Yes, applicants with arrest or conviction records will be considered for employment in accordance with applicable federal, state, and local laws.

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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.