Clinical Review Nurse I

Elevance Health•Tampa, FL

1d•Remote

About The Position

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations. The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

Requirements

Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Nice To Haves

Current unrestricted RN license required.
BS in nursing preferred.
The ability to comprehend medical policy and criteria to clearly articulate health information is strongly preferred.
Medicare Part A experience is preferred.
Prior authorization experience is preferred.
Medical Review experience is preferred.

Responsibilities

Review prior authorization requests and supporting clinical documentation to determine medical necessity and benefit coverage.
Apply strong clinical judgement, evidence-based guidelines, and medical policies to make accurate and timely authorization decisions.
Identify requests requiring additional clinical information and collaborate with providers to obtain additional information or necessary documentation, as needed.
Partner with internal clinical and operational teams to support consistent, high-quality clinical review decisions.
Escalate complex cases to the prior authorization leadership and physician reviewers in accordance with established policies and workflows.