Nurse Reviewers are responsible for conducting pre-authorization, out of network and appropriateness of treatment reviews for diagnostic imaging and other services by utilizing appropriate policies, clinical and department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits.
Location: Work from home
Schedule: Monday - Friday, 9:30 am to 6:00 pm
Internet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps)
Primary duties may include, but are not limited to:
- Receives pre-authorization requests from front-line intake
- Conducts initial medical necessity clinical screening
- Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
- Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network
- Notifies ordering physician or rendering service provider office of the pre-authorization determination decision
- Documents the results of the initial clinical review and determination in the pre-certification computer system
- Maintains confidentiality of patient and provider specific information
- Develops telephone service standards to meet departmental performance metrics
Nurse Reviewer Associate Requirements:
- Current active, valid, unrestricted RN license.
Nurse Reviewer Associate Preferred Qualifications:
- Customer service experience is preferred.
- Quality management and/or call center experience is a plus
- Any experience in clinical nursing experience is a plus
- HMO, PPO, and POS are preferred.
- Familiarity with Utilization Management Guidelines preferred.
- Familiarity with ICD-10 and CPT 4 coding preferred.
Nurse Reviewer I Requirements:
- Requires AS/BS in nursing from an accredited institution.
- Current valid and unrestricted RN license in applicable state(s) required.
- 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, and/or call center experience
Nurse Reviewer I Preferred Qualifications:
- Previous utilization and/or quality management and/or call center experience preferred.
Nurse Reviewer (Associate or Level I) Soft Skills:
- Candidates must have good computer skills and solid typing speed and accuracy.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include 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, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. 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. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.