Clinical Review Nurse I

4 weeks ago

Dallas, United States Elevance Health Full time

Clinical Review Nurse I - Medicare Part 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 Nurse Reviewer 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.

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. BS in nursing preferred.

  • 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 is preferred.

  • The ability to comprehend medical policy and criteria to clearly articulate health information is strongly preferred.

  • Processing Part B clinical claims in MCS.

  • Experience with dental claims and/or procedures is highly desired but not required.

  • Prior experience with claim review of Medicare helpful.

  • Proficient in basic math calculations with percentages.

  • Coding certification or experience with medical coding is a plus.

  • Experience reviewing medical records; and making decisions based on policy.

  • Previous Surgical Suite experience.

?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 $115,056.

Locations: Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ.

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.

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