Clinical Review Nurse I- Medicare Part A

Elevance Health, Inc.; New York (NY); On-site; USD 67,000 - 101,000; Full time

Benefits offered by this job

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase and 401k contrib

Job summary

Elevance Health is hiring a Clinical Review Nurse I for Medicare Part A to review documentation and render clinical determinations on claims. You will assess billed services for reasonableness and necessity and adapt to diverse medical review topics in Part A appeals.

The role requires an AS in nursing (BS preferred), at least 1 year of clinical experience, and an unrestricted RN license. Prior Part A/Home Health/Hospice review and ICU experience are a plus.

Qualifications

• AS in nursing required; BS in nursing preferred.
• Minimum of 1 year of clinical experience required.
• Part A Home Health and Hospice claim review experience preferred.
• Experience in surgical services and ICU strongly preferred.
• Current unrestricted RN license required.

Responsibilities

• Review documentation and make clinical determinations for Medicare claims.
• Assess services/items billed for reasonableness and necessity.
• Adapt to various medical review topics in Part A appeals.
• Conduct investigations and reviews of member and provider grievances and appeals.
• Generate written correspondence to providers, members, and regulatory entities.
• Ensure timely resolution of appeals and grievances to meet regulatory timeframes.

Skills

Clinical review

Regulatory awareness

Grievance handling

Education

AS in nursing

BS in nursing preferred

RN license

Job description

About This Role

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 role is ideal for individuals with clinical experience who can apply their knowledge to assess the necessity and reasonableness of services billed.

Highlights

• Pay: $67,200 - $100,800/year
• Location: East Syracuse, NY
• Brand/Division: Wellpoint Federal
• Schedule: Full-time, Monday through Friday, 8 am - 5 pm EST/CST

What You'll Do

• Review documentation and make clinical determinations for Medicare claims.
• Assess services/items billed for reasonableness and necessity.
• Adapt to various medical review topics in Part A appeals.
• Conduct investigations and reviews of member and provider grievances and appeals.
• Generate written correspondence to providers, members, and regulatory entities.
• Ensure timely resolution of appeals and grievances to meet regulatory timeframes.

Requirements

Education:

• AS in nursing required; BS in nursing preferred.

Experience:

• Minimum of 1 year of clinical experience required.
• Part A Home Health and Hospice claim review experience preferred.
• Experience in surgical services and ICU strongly preferred.

Licenses & Certifications:

• Current unrestricted RN license required.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase and 401k contribution

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. They are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels who are passionate about making an impact on their members and the communities they serve.