Remote Clinical Review Nurse I | Claims Adjudication

Wellpoint Federal Solutions, Inc.; Harrisburg (Dauphin County); À distance; USD 74 000 - 111 000; Plein temps

Avantages offerts par ce poste

Comprehensive benefits

Incentive programs

401k & stock plan

Résumé du poste

Wellpoint Federal is seeking a Clinical Review Nurse I (US) to review and adjudicate claims, ensuring the member receives the benefits they carry. The role emphasizes assessment of medical necessity using policy guidelines, with a focus on accuracy and timely decisions.

Hours are Monday–Friday, 8 am–5 pm EST, with some flexibility. This is a virtual full-time role with required in-person training sessions and possible relocation considerations within commuting distance to an office.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience.
• 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 preferred.

Responsabilités

• Reviews and makes medical determinations on whether a claim meets benefits.
• Assesses necessity and reasonableness of items in a valid claim using medical policy and other materials.
• Reviews and adjudicates claims.

Connaissances

Clinical assessment

Policy interpretation

Utilization Review

Formation

AS in nursing

BS in nursing preferred

Description du poste

Wellpoint Federal is seeking a Clinical Review Nurse I (US) to review and adjudicate claims, ensuring the member receives the benefits they carry. The role emphasizes assessment of medical necessity using policy guidelines, with a focus on accuracy and timely decisions.

Hours are Monday–Friday, 8 am–5 pm EST, with some flexibility. This is a virtual full-time role with required in-person training sessions and possible relocation considerations within commuting distance to an office.