Nurse Reviewer I -(CA residents only)

As a proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

Nurse Reviewer I

Location: Remote

Shift: Tuesday through Saturday or Sunday through Thursday, various early, mid, and late shifts

The Nurse Reviewer I will be in close communication with MD, providers, and members. 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.

How you will make an impact: 

Primary duties may include, but are not limited to:

• Communication with MDs, providers, and members
• Peer to peer for initial and continued stay reviews
• 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.
• Knowledge of IRF / LTAC / SNF

Minimum 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.
• Current unrestricted RN license in applicable state(s) required.

 Preferred Skills, Capabilities and Experiences: 

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

 ***Pay Transparency language is to be included on external postings ONLY when posting positions in the locations below or National 50+ miles is selected. 

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $26 to $40

 Locations: California

 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, nondiscriminatory 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. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.