Nurse Reviewer I

Elevance Health; Chicago (IL); Hybrid; Full time

Job summary

An established industry player is seeking a dedicated clinical nurse for a vital role in ensuring the appropriateness of diagnostic imaging services. This position involves conducting medical necessity screenings, collaborating with healthcare providers, and optimizing member benefits. The ideal candidate will possess a strong clinical background and a commitment to quality care. Join a forward-thinking company that values the health of its associates and communities, offering a hybrid work environment and a comprehensive benefits package. If you're passionate about making a difference in healthcare, this opportunity is perfect for you.

Benefits

Comprehensive benefits package

Incentive and recognition programs

Equity stock purchase

401k contribution

Qualifications

• 3 years of clinical nursing experience or 1 year in utilization management.
• Current unrestricted RN license required.

Responsibilities

• Conducts medical necessity screenings for diagnostic imaging services.
• Collaborates with healthcare providers for optimal member outcomes.

Skills

Clinical Nursing Experience

Utilization Management

Communication Skills

Medical Necessity Review

Education

Associate's Degree in Nursing

Bachelor's Degree

Tools

Microsoft Office

Job description

Location: This is a Virtual role, Must be located within 50 miles of a Pulse Point

Schedule: 9:30am-6:00pm, Rotating weekend shifts.

Responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.

• Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits.
• Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management.
• Partners with more senior colleagues to complete non-routine reviews.
• Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

Primary duties may include, but are not limited to:

• Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
• Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
• Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
• Follows-up to obtain additional clinical information.
• Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Minimum Requirements:

• AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license in applicable state(s) required.

Preferred Skills, Capabilities, and Experiences:

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
• BA/BS degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.
• Knowledge in Microsoft Office.

For candidates working in person or remotely in the below location(s), the salary range for this specific position is $33.81 to $44.18.

Locations: Illinois, California, Maryland

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).

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. 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. Elevance Health will also follow all relevant federal, state and local laws.

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.

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.