Clinical Review Nurse I- Medicare Part A

Elevance Health (Anthem); Collamer (NY); Hybrid; USD 67,000 - 101,000; Full time

Benefits offered by this job

Comprehensive benefits package

401k contribution

Job summary

Wellpoint Federal, a subsidiary of Elevance Health, seeks a Clinical Review Nurse I for Medicare Part A. You will review documentation, apply policies, and determine if services billed are reasonable and necessary. Expected collaboration with physicians and staff to resolve complex cases.

The role supports hybrid/remote work with required in-person training sessions and offers pathways for growth within the federal programs team.

Qualifications

• Requires AS in nursing and minimum 1 year of clinical experience or equivalent.
• Current unrestricted RN license required.
• BSN preferred.
• Strong computer skills preferred.
• Part A Medicare experience preferred.

Responsibilities

• Conduct investigations and reviews of member and provider grievances and appeals.
• Assess the necessity and reasonableness of items in claims using medical policy.
• Generate written correspondence to providers, members, and regulators.
• Ensure timely resolution of appeals and grievances to regulatory timeframes.

Skills

Clinical review

RN licensed

Medical policy interpretation

Communication with clinicians

Education

AS in nursing

BSN preferred

Tools

MAS CMS mainframe

Job description

Anticipated End Date:
2026-11-13

Position Title: Clinical Review Nurse I- Medicare Part A

Job Description:

Location: This role enables associates to work virtually full-time, with the exception of 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 an accommodation is granted as required by law .

Hours: Monday through Friday 8 am - 5 pm EST/CST.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The Clinical Review Nurse I - Medicare Part A is responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care. This position is also responsible for adapting to a wide variety of medical review topics in Part A appeals. Ability to articulate clearly with other clinicians to include medical doctors, nurses, and support personnel is required. Responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

How you will make an impact:

• Conduct investigations and reviews of members and provider grievances and appeals.
• Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
• Generates appropriate written correspondence to providers, members, and regulatory entities.
• Ensure that appeals and grievances are resolved timely to meet regulatory timeframes.

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.

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.

Preferred Capabilities, Skills and Experiences:

• BS in nursing preferred.
• Part A Home Health and Hospice claim review experience preferred.
• Strong computer skills preferred.
• Experience with MAS or other CMS mainframe system preferred.
• The ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions, while also communicating those decisions clearly and concisely preferred.
• Part A Medicare experience is strongly preferred.
• Prior experience with claims review of Medicare is preferred.
• Experience in surgical services and ICU is strongly preferred.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $67,200 to $100,800

Location(s): NY, VA

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 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 th