Clinical Review Nurse I (US)

Elevance Health (Anthem); Harrisburg (Dauphin County); Remote; USD 74,000 - 111,000; Full time

Job summary

Elevance Health is seeking a Clinical Review Nurse I to review and adjudicate claims, determining if benefits align with member plans. The role emphasizes assessing medical necessity using policy guidelines and requires nursing credentials.

The position supports virtual work with in-person training sessions occasionally; CMS residency rules apply for foreign nationals. Salary range is provided for the Connecticut location.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience providing an equivalent background.
• Foreign national applicants must meet the residency requirement of living in the United States at least three of the past five years.
• BS in nursing is preferred.

Responsibilities

• Assesses the necessity and reasonableness of items in a valid claim using medical policy and other materials.
• Reviews and adjudicates claims to determine if benefits are met.
• Reviews and makes medical determinations as to whether a claim meets the member's benefits.

Skills

Medical policy understanding

Utilization Review experience

Education

AS in nursing

BS in nursing

Job description

Anticipated End Date: 2026-10-21

Position Title: Clinical Review Nurse I (US)

Job Description

Clinical Review Nurse I

Hours: Monday through Friday 8 am - 5 pm EST based on your time zone with some flexibly.

Location: 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.

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 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

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

The clinical nurse reviewer will be responsible for reviewing and adjudicating claims.

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.
• 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

• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
• Medical management or Utilization Review experience is preferred.
• BS in nursing preferred.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $73,9200.00 to $110,880.00

Location(s): Connecticut

Benefits

• 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 the law.

Additional Information

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.

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 l