Remote Clinical Review Nurse I

Elevance Health (Anthem); Harrisburg (Dauphin County); Remote; USD 74,000 - 111,000; Full time

Job summary

Elevance Health is seeking a Clinical Review Nurse I to review and adjudicate claims, determining if benefits align with member plans. The role emphasizes assessing medical necessity using policy guidelines and requires nursing credentials.

The position supports virtual work with in-person training sessions occasionally; CMS residency rules apply for foreign nationals. Salary range is provided for the Connecticut location.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience providing an equivalent background.
• Foreign national applicants must meet the residency requirement of living in the United States at least three of the past five years.
• BS in nursing is preferred.

Responsibilities

• Assesses the necessity and reasonableness of items in a valid claim using medical policy and other materials.
• Reviews and adjudicates claims to determine if benefits are met.
• Reviews and makes medical determinations as to whether a claim meets the member's benefits.

Skills

Medical policy understanding

Utilization Review experience

Education

AS in nursing

BS in nursing

Job description

Elevance Health is seeking a Clinical Review Nurse I to review and adjudicate claims, determining if benefits align with member plans. The role emphasizes assessing medical necessity using policy guidelines and requires nursing credentials.

The position supports virtual work with in-person training sessions occasionally; CMS residency rules apply for foreign nationals. Salary range is provided for the Connecticut location.