Nurse Reviewer I (US)

Elevance Health; Tennessee; On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Merit increases

Paid holidays and PTO

Medical, dental, and vision benefits

Short/long-term disability

Job summary

Elevance Health is hiring a Nurse Reviewer I (US) in Nashville, TN to conduct preauthorization and appropriateness reviews for diagnostic imaging services. This full-time role offers a structured schedule and the autonomy to ensure quality member outcomes.

Ideal candidates have an RN license, a nursing degree (AS required, BA/BS preferred), and a track record in clinical nursing or utilization/quality management. Join a team focused on patient care quality and efficient care coordination.

Qualifications

• AS in nursing is required.
• 3 years of clinical nursing in ambulatory or hospital settings, or 1 year in utilization management/quality management.
• Current unrestricted RN license in applicable state(s).

Responsibilities

• Conduct preauthorization and appropriateness reviews for diagnostic imaging services.
• Collaborate with providers and members to ensure quality outcomes.
• Perform initial medical necessity screenings of preauthorization requests.
• Notify physicians or service providers of preauthorization determinations.
• Follow up to obtain additional clinical information and ensure proper documentation.

Skills

Clinical nursing

Utilization management

Quality management

Interdisciplinary collaboration

Education

AS in nursing

BA/BS preferred

Job description

About This Role

The Nurse Reviewer I (US) is responsible for conducting preauthorization and appropriateness of treatment reviews for diagnostic imaging services. This role is ideal for individuals seeking a position that promotes flexibility and autonomy while ensuring quality member outcomes.

Highlights

• Location: Nashville, TN
• Schedule: Full-time, Tuesday - Saturday; 8:00a - 5:00p local time

What You'll Do

• Conduct preauthorization and appropriateness of treatment reviews for diagnostic imaging services.
• Collaborate with healthcare providers and members to ensure quality member outcomes.
• Conduct initial medical necessity clinical screenings of preauthorization requests.
• Determine if clinical information meets medical necessity criteria or requires additional review.
• Notify ordering physician or service provider of preauthorization determination.
• Follow up to obtain additional clinical information.
• Ensure proper documentation and provider communication per department standards.
• Work on routine reviews with guidance from senior colleagues.
• Partner with senior colleagues for non-routine reviews.
• Learn to conduct medical necessity screenings through mentoring.

Requirements

Education:

• AS in nursing required; BA/BS degree preferred.

Experience:

• Minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or 1 year of prior utilization management, medical management, or quality management experience.

Licenses & Certifications:

• Current unrestricted RN license in applicable state(s) required.

Benefits

• Merit increases
• Paid holidays and Paid Time Off
• Medical, dental, and vision benefits
• Short and long-term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs and financial education resources

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. They are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels who are passionate about making an impact on their members and communities.