Remote Clinical Review Nurse I - Medicare Part A

Elevance Health; Indianapolis (IN); Híbrido; USD 67.000 - 101.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Hybrid work model

Benefits package

Descripción de la vacante

Elevance Health is seeking a Clinical Review Nurse I for Medicare Part A to review documentation and determine payment validity for claims. The role requires applying clinical knowledge to ensure services billed are reasonable and necessary, with diverse review topics across Part A appeals.

The ideal candidate has an RN license, an AS in nursing, and at least one year of clinical experience. This is a hybrid/virtual role with in-person onboarding and occasional training sessions.

Formación

• AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience providing equivalent background.
• Current unrestricted RN license required.
• This position is part of 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.

Responsabilidades

• Conduct investigations and reviews of members and provider grievances and appeals.
• Assess the necessity and reasonableness of items in a valid claim using medical policy and other materials.
• Generate written correspondence to providers, members, and regulatory entities.
• Ensure appeals and grievances are resolved timely to meet regulatory timeframes.

Conocimientos

Nursing

RN license

Clinical review

Medicare knowledge

CMS MAS

Educación

AS in Nursing

Herramientas

MAS CMS mainframe

Descripción del empleo

Elevance Health is seeking a Clinical Review Nurse I for Medicare Part A to review documentation and determine payment validity for claims. The role requires applying clinical knowledge to ensure services billed are reasonable and necessary, with diverse review topics across Part A appeals.

The ideal candidate has an RN license, an AS in nursing, and at least one year of clinical experience. This is a hybrid/virtual role with in-person onboarding and occasional training sessions.