Clinical Review Nurse I/II/Sr/Lead

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

About the Role

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The Clinical Review Nurse Senior is responsible for coordinating and overseeing the work of the clinical nurse reviewers and non-clinical support team.

Responsibilities

• Responds to the most complex medical issues.
• May participate in or lead cross-functional teams, projects, initiatives, and process improvement activities.
• May serve as departmental liaison to other areas of the business.
• Serves as a resource to clinical reviewers and support team.
• Comprehends complex policies and medical criteria as it pertains to members.

Requirements

• Requires AS in nursing and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license required.
• This position requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.
• If assigned to any Government Business Division entity, the applicant and incumbent fall under a "sensitive position" work designation and may be subject to additional requirements, including more stringent background checks, government clearances, segregation of duties principles, role-specific training, monitoring of daily job functions, and sensitive data handling instructions.
• The offer for this position is contingent upon Wellpoint Federal receiving final approval from the federal government to fund and commence this work.

Preferred Qualifications

• BS in nursing preferred.
• Advanced knowledge of Medicare Home Health regulations.
• Clinical Review experience.
• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.

Pay

For candidates working in person or virtually in Maine and New York, the salary range for this specific position is $79,760 to $114,655. The salary offered is based on a number of legitimate, non-discriminatory factors set by the Company, including geographic location, work experience, education, and skill level.

Benefits

In addition to salary, Elevance Health offers a comprehensive benefits package, including:

• Merit increases, paid holidays, and Paid Time Off.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• Medical, dental, vision, short and long-term disability benefits.
• Life insurance, wellness programs, and financial education resources.

Schedule

• 8-hour days, Monday-Friday.
• Hybrid Workforce Strategy: Associates are required to work at an Elevance Health location at least once per week, unless specified as primarily virtual by the hiring manager.