Remote RN Clinical Review Specialist I

Elevance Health, Inc.; St. Louis (MO); Hybrid; USD 65,000 - 85,000; Full time

Job summary

Elevance Health, Inc. is seeking a Clinical Review Nurse I to review claims for medical necessity and benefit eligibility. The role supports Wellpoint Federal's federal programs, with a virtual-eligible setup and required in-person onboarding as needed.

The candidate will assess item necessity in claims using medical policy and participate in adjudication. A valid RN license and 1+ year of clinical experience are required, with strict residency criteria for federal roles.

Qualifications

• AS in nursing with at least 1 year of clinical experience or equivalent.
• Current unrestricted RN license.
• Residency requirement: US-based living in the past 3 of 5 years per CMS policy.

Responsibilities

• Review claims for medical necessity and policy compliance.
• Adjudicate claims and determine eligibility for benefits.

Skills

Clinical review

Med policy knowledge

Claims adjudication

Education

AS in nursing

RN license (unrestricted)

Job description

Elevance Health, Inc. is seeking a Clinical Review Nurse I to review claims for medical necessity and benefit eligibility. The role supports Wellpoint Federal's federal programs, with a virtual-eligible setup and required in-person onboarding as needed.

The candidate will assess item necessity in claims using medical policy and participate in adjudication. A valid RN license and 1+ year of clinical experience are required, with strict residency criteria for federal roles.