Clinical Review Nurse I

Elevance Health (Anthem); Atlanta (GA); Hybrid; USD 70.000 - 95.000; Vollzeit

Zusammenfassung

Elevance Health seeks a Clinical Review Nurse I to assess medical necessity and determine benefits for member claims. The role supports hybrid work with required in-person training sessions and CMS residency eligibility. A valid RN license and nursing experience are essential, with AS or BS as preferred credentials.

The position emphasizes policy-based decision making, with duties including evaluating item necessity in claims using established medical criteria and policy guidelines.

Qualifikationen

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience.
• Current unrestricted RN license required.
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Aufgaben

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

Kenntnisse

AS in nursing

RN license

Clinical experience

Policy comprehension

Ausbildung

AS in nursing

BS in nursing (preferred)

Jobbeschreibung

Anticipated End Date

2026-10-24

Position Title

Clinical Review Nurse I

Job Description

Clinical Review Nurse I

Virtual

This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

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

Primary duties may include, but are not limited to:

• 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.
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants 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.

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.

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 and Influenza. 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.

Equal Employment Opportunity

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 should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review t