Nurse Reviewer I

About the role

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Responsibilities

• Conducts preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services using 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 optimize member benefits.
• Completes 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.

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.

Qualifications

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO and POS plans strongly preferred.
• Bachelor's degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.

Skills

• Strong analytical skills.
• Excellent communication and interpersonal skills.
• Ability to work independently and as part of a team.

Benefits

• Incentive and recognition programs.
• Equity stock purchase program.
• 401(k) matching.

Pay

The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Schedule

Work Schedule: Monday to Friday, 9:30 AM - 6:00 PM CST/PST.