Clinical Review Nurse I

2 weeks ago

Denver, Colorado, United States Elevance Health Full time

Shift :
Monday - Friday, 8 hour shift between 8 am and 5:30 pm CST

The Clinical Review Nurse I plays a crucial role in executing preauthorization, out-of-network, and treatment appropriateness evaluations for diagnostic imaging services by adhering to relevant policies, clinical standards, and departmental protocols.

This position involves collaboration with healthcare professionals and members to ensure the optimal, highest quality, and effective utilization of diagnostic imaging, aiming to secure favorable outcomes for members and maximize their benefits.

The role primarily encompasses routine reviews, requiring limited prior medical review experience, with guidance from more experienced colleagues and management. It also involves partnering with senior staff to complete more complex reviews.

Through hands-on experience and mentorship, the Clinical Review Nurse I will develop skills to perform medical necessity screenings of preauthorization requests, assessing the need for diagnostic imaging procedures, out-of-network services, and treatment appropriateness.

Key responsibilities include:


  • Conducting initial medical necessity assessments for exception preauthorization requests related to services outside the client health plan network.
  • Communicating preauthorization determination decisions to the ordering physician or service provider office.
  • Ensuring compliance with documentation standards, provider communication, and telephone service metrics as per departmental guidelines.

Qualifications include an Associate's degree in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital environment, or at least 1 year of prior experience in utilization management, medical management, quality management, or call center operations. Familiarity with Utilization Management and/or Home Health is highly desirable.

Elevance Health is dedicated to providing equal pay opportunities for equal work, irrespective of gender, race, or any other category protected by applicable laws.


  • The salary range mentioned reflects Elevance Health's good faith belief regarding potential compensation for this role at the time of posting. This range may be subject to change, and actual compensation may vary based on geographic location, work experience, education, and skill level.

Elevance Health is a health organization committed to enhancing lives and communities while simplifying healthcare. As a Fortune 25 company with a rich history in the healthcare sector, we seek leaders at all levels who are passionate about making a difference for our members and the communities we serve.

At Elevance Health, we foster a culture that supports our strategic goals while promoting personal and professional growth for our associates.

We offer a comprehensive range of competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless governed by a collective bargaining agreement), as well as medical, dental, vision, short and long-term disability benefits, 401(k) with matching contributions, stock purchase plans, life insurance, wellness initiatives, and financial education resources.

Elevance Health operates under a Hybrid Workforce Strategy. Unless designated as primarily virtual by the hiring manager, associates are expected to work at an Elevance Health location at least once a week, and potentially several times a week. Candidates must reside within a reasonable commuting distance of an Elevance Health location.

The health and safety of our associates and communities are paramount to Elevance Health. We require all new candidates in specific patient/member-facing roles to be vaccinated against COVID-19, in compliance with relevant federal, state, and local regulations.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will be considered for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable laws.

Applicants requiring accommodation to participate in the job application process may reach out for assistance.

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