Medicare Claims Review Nurse I - RN, Day Shift, Equity

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

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.