Nurse Reviewer I

Nurse Reviewer I

Nurse Reviewer I

Seeking RNs that have a current, unrestricted RN license in either the state of Illinois and/or California.

Location: Virtual - 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. 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 accommodation is granted as required by law.

Work Shift: Monday – Friday, 11:30 am to 8:00 pm (CST) and Alternating Weekends, 8:00 am to 12:00 pm (CST).

The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing 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 to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

How you will make an impact:

• Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
• Follows-up to obtain additional clinical information.
• Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
• Validating appeal requests.
• Manage appeal requests that come via email, fax, mailed in letters, or via live line.
• Opening and closing appeal requests following established appeal processes to maintain quality, turnaround time, and compliance requirements.
• Outreach to providers with appeal process instructions.
• Clinical review for the RBM and Surgical solution on a client specific basis.
• Notifying providers and/or members of appeal decisions.
• Maintain log of all appeal requests assigned to ensure completion, as needed.

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 either Illinois and/or California is 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.

For candidates working in person or virtually in the below locations, the pay* range for this specific position is $35.54/hr. to $55.73/hr.

Location(s): California, Illinois

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, 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.

Job Level: Non-Management Non-Exempt

Workshift: 2nd Shift (United States of America)

Job Family: MED > Licensed Nurse