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Nurse Reviewer I

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Elevance Health

2mo ago

  • Job
    Full-time
    Junior & Mid Level
  • Research & Development
    Healthcare
  • Washington

AI generated summary

  • You need an AS in nursing, 3 years of clinical experience or 1 year in utilization management, plus a current unrestricted RN license in your state.
  • You will conduct preauthorization reviews for diagnostic imaging, collaborate with providers, assess medical necessity, communicate decisions, and ensure proper documentation and follow-up.

Requirements

  • Minimum 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) 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 position allows for virtual work full-time, with required in-person training sessions.

What are the work hours for this position?

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

Are new graduates encouraged to apply?

Yes, new graduates are encouraged to apply for this position.

What will the Nurse Reviewer I be responsible for?

The Nurse Reviewer I will conduct preauthorization, out of network, and appropriateness of treatment reviews for diagnostic imaging services.

What kind of experience is required for this position?

Candidates must have 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 experience in utilization management, medical management, or quality management.

Is a current RN license required?

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

What skills are preferred for this role?

Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care plans is preferred, along with knowledge of Microsoft Office.

What is the salary range for this position?

The salary range for this position is $33.12/hr - $56.77/hr, depending on factors such as geographic location and experience.

What benefits does Elevance Health offer for this position?

Elevance Health offers a comprehensive benefits package, including paid time off, medical, dental, vision, stock purchase plan, and a 401(k) with employer match.

Are there any vaccination requirements for this role?

Yes, all new candidates in certain patient/member-facing roles are required to be vaccinated against COVID-19 and Influenza.

Does Elevance Health provide accommodations for applicants?

Yes, applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

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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.