Remote Medicare Part A Clinical Review Nurse I

Wellpoint Federal Solutions, Inc.; Collamer (NY); Remote; USD 67,000 - 101,000; Full time

Job summary

Wellpoint Federal Solutions, Inc., a subsidiary of Elevance Health, seeks a Clinical Review Nurse I for Medicare Part A to perform medical determinations on claims and support efficient appeals processes. The role emphasizes accurate documentation and collaboration with clinicians in a remote setting.

Candidates should hold an active RN license, an AS in nursing (BS preferred), and at least one year of clinical experience.

Qualifications

• Requires AS in nursing and RN license.
• Minimum of 1 year of clinical experience or equivalent background.
• Experience interpreting medical policies and applying criteria for medical review decisions.

Responsibilities

• Review documentation and make medical determinations for Medicare Part A claims.
• Investigate and review member and provider grievances and appeals; ensure timely resolutions.
• Generate written correspondence to providers, members, and regulatory entities.
• Communicate findings clearly to clinicians and other stakeholders.

Skills

RN license

Clinical review

Policy interpretation

Communication with clinicians

Education

AS in nursing

BS in nursing (preferred)

Tools

MAS CMS mainframe

Job description

Wellpoint Federal Solutions, Inc., a subsidiary of Elevance Health, seeks a Clinical Review Nurse I for Medicare Part A to perform medical determinations on claims and support efficient appeals processes. The role emphasizes accurate documentation and collaboration with clinicians in a remote setting.

Candidates should hold an active RN license, an AS in nursing (BS preferred), and at least one year of clinical experience.