Clinical Review Nurse I (US)
About The Position
Clinical Review Nurse I - Medicare Part A. 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. 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 an accommodation is granted as required by law. Hours: Monday through Friday 8 am - 5 pm EST/CST/MST in your time zone. Hours are flexible. 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.
- 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.
- 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.
- The clinical nurse reviewer will be responsible for reviewing and adjudicating claims.
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical
- dental
- vision
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
