Remote Clinical Review Nurse I — Utilization & Claims

Wellpoint Federal Solutions, Inc.; Indianapolis (IN); Hybrid; USD 65,000 - 95,000; Full time

Benefits offered by this job

Sign-on bonus

Job summary

Wellpoint Federal Solutions, Inc. is seeking a Clinical Review Nurse I to evaluate complex medical determinations for benefits and assess the necessity of items in claims. This role is Hybrid/Remote with required in-person training sessions and occasional office visits for those within commuting distance.

Minimum qualifications include an AS in nursing and at least 1 year of clinical experience, plus an unrestricted RN license. Sign-on bonus is offered and healthcare experience is valued.

Qualifications

• Requires AS in nursing and minimum of 1 year of clinical experience.
• Current unrestricted RN license required.
• BS in nursing preferred; Utilization Review experience is a plus.

Responsibilities

• Reviews and makes more complex medical determinations for benefits eligibility.
• Assesses necessity and reasonableness of items in a valid claim using medical policy and related materials.
• Communicates determinations and supports healthcare outcomes for members.

Skills

RN license

Clinical experience

Medical policy understanding

Education

AS in nursing

BS in nursing preferred

Job description

Wellpoint Federal Solutions, Inc. is seeking a Clinical Review Nurse I to evaluate complex medical determinations for benefits and assess the necessity of items in claims. This role is Hybrid/Remote with required in-person training sessions and occasional office visits for those within commuting distance.

Minimum qualifications include an AS in nursing and at least 1 year of clinical experience, plus an unrestricted RN license. Sign-on bonus is offered and healthcare experience is valued.