Clinical Review Nurse I (US)

Elevance Health (Anthem); Collamer (NY); Hybride; USD 67 000 - 101 000; Plein temps

Avantages offerts par ce poste

Benefits package

Incentives program

Equity stock

401k

Résumé du poste

Wellpoint Federal, a subsidiary of Elevance Health, seeks a Clinical Review Nurse I - Medicare Part A to review documentation and render medical determinations for payment on Medicare claims. You will assess reasonableness, apply policies, and communicate decisions clearly to clinicians and staff.

Your work includes handling Part A appeals and related review topics, collaborating with doctors and nurses, and supporting timely regulatory resolutions.

Qualifications

• AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience.
• Current unrestricted RN license.
• Residence in United States at least three of the past five years.

Responsabilités

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

Connaissances

Clinical decision making

Communication

Strong computer skills

CMS MAS experience

Formation

AS in nursing

RN license

Outils

MAS CMS mainframe

Description du poste

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.

Role Overview

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.

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 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.

Other Conditions

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.

Salary and Location

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

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution (all benefits are subject to eligibility requirements)

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.

Salary Footnote

* 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 pos