Clinical Review Nurse I (US)

Elevance Health • Harrisburg, PA

19h • Remote

About The Position

The Clinical Review Nurse I reviews claims and makes medical determinations about whether the claims meet the benefits carried by the member. The nurse assesses the necessity and reasonableness of items supplied in a valid claim by applying medical policy and other materials, and is responsible for reviewing and adjudicating claims.

This is a virtually full-time role, with required in-person training sessions. The schedule is Monday through Friday, 8 a.m. to 5 p.m. Eastern, based on the associate’s time zone, with some flexibility. Alternate locations may be considered for candidates within commuting distance of an office; applicants outside a reasonable commuting distance from the posting location may not be considered unless accommodation is required by law.

The position is within Wellpoint Federal, a subsidiary of Elevance Health that supports federal programs through claims administration, data, and care-delivery solutions. Under CMS TDL 190275, foreign national applicants must have lived in the United States for at least three of the past five years. Government Business Division assignments may carry additional requirements, including more stringent or frequent background checks or government clearances, role-specific training, monitoring, and sensitive-data handling instructions.

Requirements

• Associate degree in nursing and at least 1 year of clinical experience, or an equivalent combination of education and experience.
• For foreign national applicants to this Wellpoint Federal position: must have lived in the United States for at least three of the past five years.

Nice To Haves

• Ability to comprehend medical policy and criteria and clearly articulate health information.
• Medical management or Utilization Review experience.
• Bachelor of Science in nursing.

Responsibilities

• Assess the necessity and reasonableness of items supplied in a valid claim using medical policy and other materials.
• Review and adjudicate claims.
• Make medical determinations about whether claims meet the benefits carried by the member.

Benefits

• Comprehensive benefits package, subject to eligibility requirements.
• Incentive and recognition programs.
• Equity stock purchase and 401(k) contribution.
• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs, unless covered by a collective bargaining agreement.
• Medical insurance.
• Dental insurance.
• Vision insurance.
• Short- and long-term disability benefits.
• 401(k) matching.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree