Remote Nurse Reviewer I: Utilization Management

Elevance Health; Nashville (TN); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Elevance Health in Nashville, TN, is seeking a Nurse Reviewer I to conduct preauthorization and utilization reviews for diagnostic imaging. You will collaborate with providers and members to ensure appropriate use of services and alignment with clinical guidelines.

The role requires an AS in nursing with RN licensure and exposure to utilization management, with hybrid work options and periodic in-person training. Training and onboarding are provided to develop medical necessity screening skills.

Qualifications

• AS in nursing and minimum 3 years of clinical nursing experience in ambulatory or hospital setting, or minimum 1 year in utilization management/quality management/call center.
• Current unrestricted RN license in applicable state(s) required.

Responsibilities

• Conducts initial medical necessity screening for diagnostic imaging preauthorization.
• Reviews initial medical necessity for exception preauthorization outside client network.
• Notifies ordering physician or provider office of preauthorization determinations.
• Follows up to obtain additional clinical information as needed.
• Ensures proper documentation and provider communication per department standards.

Skills

Utilization Management Guidelines

ICD-9 CPT-4 coding

Managed health care knowledge

Education

AS in Nursing

BA/BS degree preferred

Job description

Elevance Health in Nashville, TN, is seeking a Nurse Reviewer I to conduct preauthorization and utilization reviews for diagnostic imaging. You will collaborate with providers and members to ensure appropriate use of services and alignment with clinical guidelines.

The role requires an AS in nursing with RN licensure and exposure to utilization management, with hybrid work options and periodic in-person training. Training and onboarding are provided to develop medical necessity screening skills.