Clinical Review Nurse I

Elevance Health; Wilmington (DE); Remote; USD 65,000 - 90,000; Full time

Job summary

Elevance Health is seeking a Clinical Review Nurse I to review and determine whether a claim meets the benefits the member carries. This virtual, full-time role offers flexibility with in-person training sessions and potential alternate locations within commuting distance.

The role focuses on medical necessity assessment and adherence to policy, with a current unrestricted RN license and a minimum of 1 year of clinical experience required.

Qualifications

• Requires AS in nursing and at least 1 year of clinical experience.
• Alternatively, any combination of education and experience providing equivalent background.
• Current unrestricted RN license required.
• Residency requirement: must reside in the United States at least three of the past five years (Wellpoint Federal division).

Responsibilities

• Assesses the necessity and reasonableness of items in a valid claim using medical policy and materials.

Skills

Clinical assessment

Policy interpretation

Education

AS in nursing

BS in nursing (preferred)

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 is 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.

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.

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 Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment 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 the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/).