Clinical Review Nurse I (US)

Clinical Review Nurse I (US)

Clinical Review Nurse I

Sign on Bonus: $3500.

Location: This role enables associates to work virtually full-time, with the exception of 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that 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 an accommodation is granted as required by law.

Hours: Monday through Friday 8 am - 5 pm EST based on your time zone with some flexibly.

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 I is responsible for reviewing and making more complex medical determinations as to whether a claim meets the benefits the member carries.

How you will make an impact:

• Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.

Minimum Requirements:

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license required.
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Preferred Skills, Capabilities, and Experiences:

• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
• Medical management or Utilization Review experience is preferred.
• BS in nursing preferred.

If this job is 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 beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse