Clinical Review Nurse I- Medicare Part A

Elevance Health•Syracuse, NY

17h•Hybrid

About The Position

The Clinical Review Nurse I - Medicare Part A reviews documentation and makes clinical determinations for payment of claims submitted to Medicare. The role applies clinical knowledge to assess whether billed services and items are reasonable and necessary, supported by national and local policies, consistent with accepted billing and coding practices, and compliant with standards of medical care. The nurse adapts to a wide variety of medical review topics in Part A appeals and communicates clearly with physicians, nurses, and support personnel. The role also determines whether claims meet the benefits carried by the member. This position is with Wellpoint Federal, a subsidiary of Elevance Health that supports federal programs through claims administration, data, and care delivery services. The role is virtually full-time except for required in-person training sessions; alternate locations may be considered for candidates within commuting distance of an office. The stated schedule is Monday through Friday, 8 a.m. to 5 p.m. EST/CST.

Requirements

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

Nice To Haves

Bachelor of Science in nursing.
Part A Home Health and Hospice claim review experience.
Strong computer skills.
Experience with MAS or another CMS mainframe system.
Ability to understand medical policies and apply criteria to make informed medical review decisions, and communicate those decisions clearly and concisely.
Medicare Part A experience.
Prior Medicare claims review experience.
Experience in surgical services and ICU.

Responsibilities

Conduct investigations and reviews of member and provider grievances and appeals.
Assess the necessity and reasonableness of items supplied in valid claims using medical policy and other materials.
Generate written correspondence to providers, members, and regulatory entities.
Ensure appeals and grievances are resolved within regulatory timeframes.
Review documentation and make clinical determinations for Medicare Part A claims.
Determine whether claims meet the member's benefits and whether billed services or items are supported by applicable policies, accepted billing and coding practices, and standards of medical care.