Remote RN – Medicare Part A Clinical Review

Elevance Health; Collamer (NY); Remote; USD 67,000 - 101,000; Full time

Benefits offered by this job

Benefits package

Job summary

Elevance Health, Inc. seeks a Clinical Review Nurse I to review documentation and render clinical determinations for Medicare Part A claims.

You will apply nursing expertise to assess reasonableness and necessity, guided by policies and coding standards, collaborating with clinicians as needed. This is a remote role with required in-person training sessions; Wellpoint Federal prioritizes onboarding, regulatory compliance, and high-quality patient reviews.

Qualifications

• Requires AS in nursing and minimum 1 year of clinical experience.
• Current unrestricted RN license required.
• CMS residency requirement for Wellpoint Federal per policy.

Responsibilities

• Conduct investigations and reviews of member and provider grievances and appeals.
• Assess necessity and reasonableness of items in a claim using medical policy.
• Generate written correspondence to providers, members, and regulatory entities.
• Ensure timely resolution of appeals and grievances to meet regulatory timeframes.

Skills

RN license

AS in nursing

clinical experience

communication

computer skills

Education

AS in nursing

BS in nursing (preferred)

Tools

MAS CMS mainframe

Job description

Elevance Health, Inc. seeks a Clinical Review Nurse I to review documentation and render clinical determinations for Medicare Part A claims.

You will apply nursing expertise to assess reasonableness and necessity, guided by policies and coding standards, collaborating with clinicians as needed. This is a remote role with required in-person training sessions; Wellpoint Federal prioritizes onboarding, regulatory compliance, and high-quality patient reviews.