Clinical Review Nurse I (US)

Elevance Health•Indianapolis, IN

1d•$67,200 - $100,800•Remote

About The Position

Wellpoint Federal, a subsidiary of Elevance Health, supports federal programs by delivering solutions across claims administration, data, and care delivery to improve health outcomes for federal populations. The Clinical Review Nurse I - Medicare Part A is responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care. This position is also responsible for adapting to a wide variety of medical review topics in Part A appeals. Ability to articulate clearly with other clinicians to include medical doctors, nurses, and support personnel is required. 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.
Current unrestricted RN license required.
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

BS in nursing preferred.
Part A Home Health and Hospice claim review experience preferred.
Strong computer skills preferred.
Experience with MAS or other CMS mainframe system preferred.
The ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions, while also communicating those decisions clearly and concisely preferred.
Part A Medicare experience is strongly preferred.
Prior experience with claims review of Medicare is preferred.
Experience in surgical services and ICU is strongly preferred.

Responsibilities

Conduct investigations and reviews of members and provider grievances and appeals.
Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensure that appeals and grievances are resolved timely to meet regulatory timeframes.