Nurse Reviewer I (US)

Elevance Health (Anthem); Nashville (TN); Hybrid; USD 55,000 - 75,000; Full time

Benefits offered by this job

Hybrid work model

Medical & dental benefits

401(k)

Job summary

Elevance Health in Nashville, TN, is seeking a Nurse Reviewer I (US) to conduct preauthorization, out-of-network, and treatment appropriateness reviews for diagnostic imaging, using clinical guidelines and policies. This role collaborates with providers and members to promote high-quality, cost-effective care.

The position supports a hybrid/virtual work arrangement with in-person onboarding and training sessions. Work Schedule is Tuesday–Saturday, 8:00 a.m.–5:00 p.m.

Qualifications

• Requires AS in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting.
• Or a minimum of 1 year of prior utilization management, medical management and/or quality management and/or call center experience.
• Current unrestricted RN license in applicable state(s).

Responsibilities

• Conducts initial medical necessity clinical screening to determine if information meets criteria or requires further review.
• Performs initial medical necessity review of exception preauthorization requests for services outside the client network.
• Notifies ordering physician or rendering service provider of the preauthorization decision.
• Follows up to obtain additional clinical information as needed.
• Ensures proper documentation and provider communication per department standards.

Skills

Clinical nursing

Utilization management

Call center experience

Education

AS in Nursing

BA/BS degree

Job description

Nurse Reviewer I (US)

Location: 22 Century Boulevard, STE 310, Nashville, TN

Virtual: 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.

Work Schedule: Tuesday - Saturday ; 8:00a - 5:00p local time.

Training Schedule: Monday - Friday; 8:00a - 4:30p CST for at least 3 weeks.

The Nurse Reviewer I (US) will be 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 assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

How you will make an impact

• 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

Requires 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.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse

Who We Are

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. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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