Remote RN: Medicare Part A Clinical Review

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

Benefits offered by this job

Comprehensive benefits package

401k contribution

Job summary

Wellpoint Federal, a subsidiary of Elevance Health, seeks a Clinical Review Nurse I for Medicare Part A. You will review documentation, apply policies, and determine if services billed are reasonable and necessary. Expected collaboration with physicians and staff to resolve complex cases.

The role supports hybrid/remote work with required in-person training sessions and offers pathways for growth within the federal programs team.

Qualifications

• Requires AS in nursing and minimum 1 year of clinical experience or equivalent.
• Current unrestricted RN license required.
• BSN preferred.
• Strong computer skills preferred.
• Part A Medicare experience preferred.

Responsibilities

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

Skills

Clinical review

RN licensed

Medical policy interpretation

Communication with clinicians

Education

AS in nursing

BSN preferred

Tools

MAS CMS mainframe

Job description

Wellpoint Federal, a subsidiary of Elevance Health, seeks a Clinical Review Nurse I for Medicare Part A. You will review documentation, apply policies, and determine if services billed are reasonable and necessary. Expected collaboration with physicians and staff to resolve complex cases.

The role supports hybrid/remote work with required in-person training sessions and offers pathways for growth within the federal programs team.