Clinical Review Nurse I (US)

Elevance Health•St. Louis, MO

23h•Remote

About The Position

The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries. 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

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.
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.
Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
Home Health or Hospice is preferred.
Knowledge of Medicare guidelines preferred.

Responsibilities

Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
Reviewing and adjudicating claims.