Nurse Reviewer I

3 weeks ago

Cerritos, United States Elevance Health Full time

Job Family: MED > Licensed Nurse
- Type: Full time
- Date Posted: Apr 17, 2024
- Anticipated End Date: May 31, 2024
- Reference: JR113706

**Description**:
**Nurse Reviewer I**

**Location**:Within 50 miles of a pulse point in the following states:

- California
- Washington
- Nevada

**Shift**: An 8-hour shift from 9:30 am - 6 pm **P **ST**

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 clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- 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.

**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 CA 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.
- Ability to work 9:30 am - 6 pm PST
- Ability to work weekends if necessary
- New grads are encouraged to apply
- Knowledge in Microsoft Office (Word, Excel, Visio)

**Locations**: California, Nevada, Washington State
- 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.

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 progr

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