Remote RN: Clinical Review & Claims Adjudication I

Elevance Health, Inc.; Chandler (AZ); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Elevance Health, Inc. is seeking a Clinical Review Nurse I to review claims for medical necessity and coverage within Wellpoint Federal. The role can be performed virtually with required in-person trainings and occasional office visits within a reasonable commuting distance.

You will adjudicate claims using medical policy and ensure alignment with program requirements. Candidates should have an RN license, at least one year of clinical experience, and AS in nursing; a BS in nursing is preferred.

Qualifications

• Requires AS in nursing and minimum 1 year of clinical experience; RN license required.
• Knowledge of Medicare guidelines or policy experience is a plus.
• BS in nursing preferred for advanced roles and responsibilities.

Responsibilities

• Review and adjudicate claims to determine medical necessity based on policy.
• Assess items for reasonableness and benefits coverage in the member's claim.

Skills

RN license

Clinical experience

AS in nursing

Education

AS in nursing

BS in nursing preferred

Job description

Elevance Health, Inc. is seeking a Clinical Review Nurse I to review claims for medical necessity and coverage within Wellpoint Federal. The role can be performed virtually with required in-person trainings and occasional office visits within a reasonable commuting distance.

You will adjudicate claims using medical policy and ensure alignment with program requirements. Candidates should have an RN license, at least one year of clinical experience, and AS in nursing; a BS in nursing is preferred.