Clinical Review Nurse I (US)

Wellpoint Federal Solutions, Inc.; Harrisburg (Dauphin County); À distance; USD 74 000 - 111 000; Plein temps

Avantages offerts par ce poste

Comprehensive benefits

Incentive programs

401k & stock plan

Résumé du poste

Wellpoint Federal is seeking a Clinical Review Nurse I (US) to review and adjudicate claims, ensuring the member receives the benefits they carry. The role emphasizes assessment of medical necessity using policy guidelines, with a focus on accuracy and timely decisions.

Hours are Monday–Friday, 8 am–5 pm EST, with some flexibility. This is a virtual full-time role with required in-person training sessions and possible relocation considerations within commuting distance to an office.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience.
• 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 preferred.

Responsabilités

• Reviews and makes medical determinations on whether a claim meets benefits.
• Assesses necessity and reasonableness of items in a valid claim using medical policy and other materials.
• Reviews and adjudicates claims.

Connaissances

Clinical assessment

Policy interpretation

Utilization Review

Formation

AS in nursing

BS in nursing preferred

Description du poste

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 flexibility. 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.

Company

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.

Responsibilities

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.
• Foreign national applicants must 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.

Salary

• The salary for this specific position is $73,9200.00 to $110,880.00.

Benefits

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

Work Hours and Location

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

Location: Connecticut. Additional partner to alternate if within commuting distance of office. Candidates not within reasonable commuting distance from posting location(s) will not be considered unless accommodation is granted as required by law.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse

Agency Policy

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.

About Us

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.

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.

Vaccination Policy

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.

Equal Employment Opportunity

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.

Accessibility Accommodation

Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact.

Legal Disclosures

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.

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words — the job is posted until 3/13, not through 3/13.

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