Nurse Reviewer 1

The Nurse Reviewer 1 role enables associates to work virtually full-time, with the exception of required in-person training sessions, promoting productivity, work-life integration, and essential face-to-face onboarding and skill development.

About the role

This role conducts preauthorization, out-of-network, and appropriateness of treatment reviews for diagnostic imaging services using appropriate policies, clinical, and department guidelines. It involves collaborating with healthcare providers and members to ensure the most appropriate, high-quality, and effective use of diagnostic imaging to improve member outcomes and benefit optimization.

Responsibilities

• Conducts initial medical necessity clinical screening and determines if initial clinical information meets medical necessity criteria or requires additional review.
• Reviews exception preauthorization requests for services outside the client health plan network.
• Notifies ordering physicians or rendering service providers of preauthorization determinations and follows up to obtain additional clinical information.
• Safeguards proper documentation, provider communication, and telephone service adherence to department standards and performance metrics.

Requirements

• Requires an AS in nursing and at least 3 years of clinical nursing experience in an ambulatory or hospital setting, or 1 year of prior utilization management, medical management, and/or quality management experience, or a combination of education and experience providing an equivalent background.
• A current unrestricted RN license in the applicable state(s) is required.

Preferred Skills, Capabilities & Experiences

• A BA/BS degree is preferred.
• Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO, and POS plans is strongly preferred.
• Previous utilization and/or quality management and/or call center experience is preferred.

Benefits

The Nurse Reviewer 1 role offers a range of market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long-term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs, and financial education resources.

Pay

Compensation details are confidential and not specified in this posting.

Schedule

The Nurse Reviewer 1 works Tuesday-Saturday or Sunday-Thursday, 8:00a - 5:00p local time. Training occurs Monday-Friday, 8:00a - 4:30p CST for at least 3 weeks.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

We offer a hybrid workforce strategy where associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.