Nurse Reviewer I

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

Job summary

A leading healthcare company is seeking a Nurse Reviewer I for a virtual position. The role involves conducting preauthorization and treatment appropriateness reviews for diagnostic imaging. Candidates should have nursing experience and an RN license. This position offers flexibility and supports work-life balance. Join a dedicated team focused on promoting optimal member outcomes through high-quality care.

Benefits

Comprehensive benefits packages

Incentive programs

401(k)

Stock purchase options

Qualifications

• 3 years clinical nursing experience or 1 year in utilization/medical management.
• Current unrestricted RN license in applicable states.

Responsibilities

• Conduct initial medical necessity screenings.
• Review exception preauthorization requests.
• Notify providers of preauthorization decisions.

Skills

Utilization Management Guidelines

ICD-9 coding

CPT-4 coding

Managed healthcare plans

Microsoft Office

Education

Associate Degree in Nursing

Bachelor’s Degree

Job description

Join to apply for the Nurse Reviewer I role at Elevance Health

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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 including radiology, cardiology, and oncology.

Nurse Reviewer I

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

In-Office Expectation: Virtual, with required in-person training sessions. This setup offers maximum flexibility and autonomy, supporting productivity and work-life balance.

Shift: Monday-Friday, 8 AM – 5 PM PDT/MDT/CDT, depending on location. Future shift changes may include Tuesday – Saturday or Sunday – Thursday, 8 AM – 5 PM.

Training: The first three weeks of training are conducted in CDT, regardless of your time zone.

The Nurse Reviewer I conducts preauthorization, out-of-network, and treatment appropriateness reviews for diagnostic imaging, using policies and clinical guidelines. Collaborates with healthcare providers and members to ensure high-quality, appropriate diagnostic imaging use, promoting optimal member outcomes.

This role involves routine reviews with limited or no prior medical review experience, requiring guidance from senior colleagues or management. Partners with senior staff on non-routine reviews. Gains experience and mentorship in conducting clinical screenings for medical necessity, out-of-network services, and treatment appropriateness.

Primary Responsibilities

• Conduct initial medical necessity screening to determine if clinical information meets criteria or requires further review.
• Review exception preauthorization requests for out-of-network services.
• Notify physicians or providers of preauthorization decisions.
• Follow-up for additional clinical information as needed.
• Maintain proper documentation, provider communication, and telephone service standards.

Minimum Requirements

• Associate Degree in Nursing (ASN) and at least 3 years of clinical nursing experience in ambulatory or hospital settings, or 1 year of utilization/medical/quality management experience, or equivalent education and experience.
• Current unrestricted RN license in applicable state(s).

Preferred Skills and Experience

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, managed healthcare plans (HMO, PPO, POS).
• Bachelor’s Degree (preferred).
• Experience in utilization, quality management, or call centers (preferred).
• Proficiency in Microsoft Office products.

Salary range: $29.96 - $56.77 per hour, based on location and experience. Locations include CA, CO, IL, MN, NV, and WA. Benefits include comprehensive packages, incentive programs, 401(k), stock purchase, and more.

Elevance Health is an equal opportunity employer. All qualified applicants will be considered without regard to protected categories. Candidates must be vaccinated against COVID-19 and Influenza unless an exemption is provided.