Remote Clinical Review Nurse I — Assess Benefit Validity

Elevance Health (Anthem); Atlanta (GA); Hybrid; USD 70,000 - 95,000; Full time

Job summary

Elevance Health seeks a Clinical Review Nurse I to assess medical necessity and determine benefits for member claims. The role supports hybrid work with required in-person training sessions and CMS residency eligibility. A valid RN license and nursing experience are essential, with AS or BS as preferred credentials.

The position emphasizes policy-based decision making, with duties including evaluating item necessity in claims using established medical criteria and policy guidelines.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience.
• Current unrestricted RN license required.
• This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Responsibilities

• Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.

Skills

AS in nursing

RN license

Clinical experience

Policy comprehension

Education

AS in nursing

BS in nursing (preferred)

Job description

Elevance Health seeks a Clinical Review Nurse I to assess medical necessity and determine benefits for member claims. The role supports hybrid work with required in-person training sessions and CMS residency eligibility. A valid RN license and nursing experience are essential, with AS or BS as preferred credentials.

The position emphasizes policy-based decision making, with duties including evaluating item necessity in claims using established medical criteria and policy guidelines.