Clinical Review Nurse I
1 month ago
Anticipated End Date:
2024-11-22
Position Title:
Clinical Review Nurse I
Job Description:
Clinical Review Nurse I - Medicare Part A & B
National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.
Location: This is a virtual position and preferred candidates reside within 50 miles of an Elevance Health PulsePoint location.
Hours: Monday through Friday 8 am - 5 pm EST or CST. Hours are flexible.
The Clinical Review Nurse I is responsible for reviewing and making 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.
* Applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care.
* Adapts to a wide variety of medical review topics and multiple Medicare lines of business to include Part A, Part B, and DME.
* Articulates clearly with other clinicians including medical doctors, nurses, and support personnel via teleconference education sessions.
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 NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States at least three of the past five years
Preferred Skills, Capabilities, and Experiences:
* BS in nursing preferred.
* Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
* Medical Review experience is a plus.
* Working experience with Microsoft Outlook, Word, and Excel.
* Working knowledge of Medicare rules and regulations is a plus.
* Must have high-speed internet and the capability of a wired connection to meet equipment requirements.
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
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
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.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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 elevancehealthjobssupport@elevancehealth.com for assistance.
-
Clinical Nurse Department Pool I
1 month ago
Tampa, United States BayCare Health System Full timeAt BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that’s built on a...
-
Clinical Nurse Department Pool I
2 weeks ago
Tampa, United States BayCare Health System Full timeAt BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that’s built on a...
-
Clinical Data Review Specialist
2 weeks ago
Tampa, Florida, United States HireOps Staffing LLC Full timeAbout the RoleHireOps Staffing LLC is seeking a highly skilled Clinical Data Review Specialist to join our team. This contract position offers a competitive salary and the opportunity to work remotely.
-
Bill Review Analyst I
3 weeks ago
Tampa, United States CorVel Corporation Full timeResponsible for review, auditing and data-entry of medical bills for multiple states and lines of business.ESSENTIAL FUNCTIONS & RESPONSIBILITIES:Responsible for auditing medical bills to ensure that they are appropriate and adhere to the State Fee Schedules, customer guidelines and PPO discountsPosition requires knowledge of the Fee Schedule and the...
-
Field Clinical Representative
3 weeks ago
Tampa, United States Inspire Medical Systems I Full timeJob DescriptionJob DescriptionABOUT INSPIRE MEDICAL SYSTEMSInspire is the first of its kind medical device designed to make a difference in the lives of those living with Obstructive Sleep Apnea (OSA). We are revolutionizing the sleep industry with our FDA-approved medical device, designed to reduce OSA severity for those who cannot tolerate or get...
-
Clinical Research Nurse
1 month ago
Tampa, United States The Tampa General Hospital Foundation Inc Full timeDepartment Profile The TGH Cancer Institute Clinical Research Office is the centralized clinical research enterprise to support all Oncology research. As the hub for all cancer research activities, this office supports all aspects of research including but not limited to trial feasibility, activation, recruitment, and enrollment into Phase I-IV clinical...
-
Clinical Care Assistant I
5 days ago
Tampa, United States Sanitas Full timeJob DetailsJob LocationTampa - Hillsborough - Tampa, FLPosition TypeFull TimeEducation Level2 Year DegreeTravel PercentageUp to 5%Job CategoryClinical OperationsDescription"Sanitas is a global healthcare organization expanding across the United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and...
-
Clinical Care Assistant I
2 months ago
Tampa, United States Sanitas Full timeJob DetailsJob LocationTampa - Hillsborough - Tampa, FLPosition TypeFull TimeEducation Level2 Year DegreeTravel PercentageUp to 5%Job CategoryClinical OperationsDescription"Sanitas is a global healthcare organization expanding across the United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and...
-
Clinical Nurse Coordinator Progressive Care
4 weeks ago
Tampa, United States HCA Florida West Tampa Hospital Full timeDescription IntroductionDo you currently have an opportunity to make a real impact with your work? With over 2,000 sites of care and serving over 31.2 million patient interactions every year, nurses at HCA Florida West Tampa Hospital have the opportunity to make a real impact. As a(an) Clinical Nurse Coordinator you can be a part of change.BenefitsHCA...
-
Clinical Nurse Coordinator Progressive Care
3 weeks ago
Tampa, United States HCA Florida West Tampa Hospital Full timeDescription Introduction Do you currently have an opportunity to make a real impact with your work? With over 2,000 sites of care and serving over 31.2 million patient interactions every year, nurses at HCA Florida West Tampa Hospital have the opportunity to make a real impact. As a(an) Clinical Nurse Coordinator you can be a part of change. Benefits HCA...
-
Pediatrician / New Resident- PT or Full time
4 weeks ago
Tampa, United States Clinical Professional Connections Full timeCompany Overview Privately owned by a Primary Care Pediatric. Our pediatric clinic offers comprehensive knowledge and customized treatment plans. Our goal is to promote family wellness, and we do this by dedicating ourselves to integrate services for children of all ages. We are also passionate about educating our community in providing a safe and healthy...
-
Pediatrician / New Resident- PT or Full time
2 months ago
Tampa, United States Clinical Professional Connections Full timeCompany Overview Privately owned by a Primary Care Pediatric. Our pediatric clinic offers comprehensive knowledge and customized treatment plans. Our goal is to promote family wellness, and we do this by dedicating ourselves to integrate services for children of all ages. We are also passionate about educating our community in providing a safe and healthy...
-
Clinical Nurse Coordinator Med Surg
1 day ago
Tampa, United States HCA Florida South Tampa Hospital Full timeDescription IntroductionDo you want to be appreciated daily? Our nurses are celebrated for being on the front line, empathetic for patients. At HCA Florida South Tampa Hospital our nurses set us apart from any other healthcare provider. We are seeking a(an) Clinical Nurse Coordinator Med Surg to join our healthcare family.BenefitsHCA Florida South Tampa...
-
Clinical Nurse Coordinator Med Surg
3 months ago
Tampa, United States HCA Florida South Tampa Hospital Full timeDescription IntroductionDo you have the career opportunities as a(an) Clinical Nurse Coordinator Med Surg you want in your current role? We invest in what matters most to nurses like you – at home, at work, and at every stage in your career. We have an exciting opportunity for you to join HCA Florida South Tampa Hospital which is a part of the nation’s...
-
Clinical Care Assistant I
7 days ago
Tampa, United States Sanitas Full timeJob DetailsJob LocationWest Florida Region - Tampa, FLPosition TypeFull TimeEducation Level2 Year DegreeTravel PercentageUp to 5%Job CategoryClinical OperationsDescriptionSanitas is a global healthcare organization expanding across United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources...
-
Clinical Care Assistant I
7 months ago
Tampa, United States Sanitas Full timeJob DetailsJob LocationWest Florida Region - Tampa, FLPosition TypeFull TimeEducation Level2 Year DegreeTravel PercentageUp to 5%Job CategoryClinical OperationsDescriptionSanitas is a global healthcare organization expanding across United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources...
-
Tampa, United States Qlarant Full timeQlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving...
-
Clinical - Pharmacist 1
3 days ago
Tampa, United States Axelon Full timeRemote, Schedule : 9am - 6pm EST , No OT Job Description: Summary:The main function of a pharmacist is to dispense prescription medications to patients and offer expertise in the safe use of prescriptions. They also may conduct health and wellness screenings, provide immunizations, oversee the medications given to patients, and provide advice on healthy...
-
Clinical - Pharmacist 1
7 hours ago
Tampa, United States Axelon Full timeRemote, Schedule : 9am - 6pm EST , No OT Job Description: Summary:The main function of a pharmacist is to dispense prescription medications to patients and offer expertise in the safe use of prescriptions. They also may conduct health and wellness screenings, provide immunizations, oversee the medications given to patients, and provide advice on healthy...
-
Clinical Nurse Coordinator PACU
3 months ago
Tampa, United States HCA Florida West Tampa Hospital Full timeDescription IntroductionDo you have the career opportunities as a(an) Clin Nurse Coord SP you want in your current role? We invest in what matters most to nurses like you – at home, at work, and at every stage in your career. We have an exciting opportunity for you to join HCA Florida West Tampa Hospital which is a part of the nation’s leading provider...
