Clinical Review Nurse I

Anticipated End Date:

2024-12-11

Position Title:

Clinical Review Nurse I

Job Description:

Clinical Review Nurse I

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.

The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries and for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare.

How you will make an impact:

* Conducts investigations and reviews of member and provider grievances and appeals.


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


* Generates appropriate written correspondence to providers, members, and regulatory entities.


* Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.



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.


* Medicare skilled nursing facility, inpatient, or Part B of A experience is a plus.


* Proficiency in computer skills.


* Experience with Medicare Appeals System (MAS) or other CMS mainframe systems is highly desirable.


* Prior experience with claims review is a plus.


* Proficiency in understanding medical policies and criteria and effectively communicating health information to fellow clinicians, including physicians, nurses, and support staff, is highly desirable.



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.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $63,920 to $100,674.

Locations: New York; Maryland.

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.

* 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.

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.