Nurse

Elevance Health; Mendota (MN); Remote; USD 60,000 - 80,000; Full time

Job summary

Elevance Health is seeking a Nurse Reviewer I to conduct preauthorization and treatment appropriateness reviews for diagnostic imaging. This virtual role requires an AS in nursing, an RN license, and offers a flexible schedule with a focus on promoting high-quality care. Join a team dedicated to ensuring optimal member outcomes while enjoying comprehensive benefits.

Benefits

Comprehensive health plans

Incentive programs

401(k)

Stock purchase

Qualifications

• Current unrestricted RN license in applicable state(s).
• At least 3 years of clinical nursing experience or 1 year in utilization/medical management.

Responsibilities

• Conducting initial medical necessity screenings.
• Review of exception preauthorization requests.
• Communicating decisions to providers.

Skills

Familiarity with Utilization Management Guidelines

ICD-9

CPT-4 coding

Managed healthcare plans

Proficiency in Microsoft Office

Education

AS in nursing

BA/BS degree preferred

Job description

Be Part of an Extraordinary Team

A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit-management leader in Illinois. Our platform delivers significant cost-of-care savings across clinical domains such as radiology, cardiology, and oncology.

Nurse Reviewer I

Location: This is a virtual position open to candidates in Pacific, Mountain, or Central Time Zones.

In Office Expectation: Virtual, with required in-person training sessions. This role offers maximum flexibility and supports work-life balance.

Shift: Monday-Friday, 8 AM - 5 PM PDT, MDT, or CDT, depending on location. Potential future shifts: Tuesday - Saturday or Sunday - Thursday, 8 AM - 5 PM.

Training: First three weeks conducted in CDT, regardless of your time zone.

The Nurse Reviewer I conducts preauthorization and treatment appropriateness reviews for diagnostic imaging, utilizing clinical guidelines and policies. Collaborates with healthcare providers and members to promote appropriate, high-quality care, ensuring optimal member outcomes.

Works on routine reviews with guidance, and partners with senior colleagues on non-routine cases. Gains experience in medical necessity screenings for diagnostic imaging and treatment appropriateness.

How You Will Make an Impact

Primary duties include:

• Conducting initial medical necessity screenings and determining if clinical information meets criteria or requires further review.
• Review of exception preauthorization requests for out-of-network services.
• Communicating decisions to providers.
• Following up for additional clinical information.
• Ensuring proper documentation and communication standards are met.

Minimum Requirements

• AS in nursing and at least 3 years of clinical nursing experience, or 1 year in utilization/medical management, or equivalent education and experience.
• Current unrestricted RN license in applicable state(s).

Preferred Skills and Experience

• Familiarity with Utilization Management Guidelines, ICD-9, CPT-4 coding, and managed healthcare plans.
• BA/BS degree preferred.
• Previous utilization, quality management, or call center experience preferred.
• Proficiency in Microsoft Office.

Compensation and Location

Salary range: $29.96 - $56.77 per hour, based on location and experience. Locations include CA, CO, IL, MN, NV, WA.

Benefits include comprehensive health plans, incentive programs, 401(k), stock purchase, and more. Elevance Health is committed to equal pay and equal opportunity employment.

Additional Information

Elevation of health and safety standards, including vaccination requirements, are part of our commitment to community health. Candidates must reside within 50 miles or 1-hour commute of a relevant location unless specified otherwise.

We are an equal opportunity employer and support accommodations for applicants with disabilities. For assistance, contact [e-mail].