Nurse Reviewer I (Nclex)

Elevance Health

14d • Hybrid

About The Position

Nurse Reviewer I Location: This role enables associates to work virtually full-time, except for 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. This position will be based in either San Juan, PR or Mayaguez, PR. 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. A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans. Schedule: This position will work an 8-hour shift Monday through Friday with a work shift scheduled between the operational hours of 8:00 am – 6:00 pm (AST). Additional hours, including weekends or holidays, may be required based on operational needs. The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews by utilizing appropriate policies, clinical and department guidelines. How You Will Make an Impact: Primary duties may include, but are not limited to: Conduct clinical medication reviews requiring advanced nursing assessment and critical thinking. Analyze claims and medication history to identify risks and recommend safe, evidence-based alternatives. Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network. Notifies ordering physician or rendering service provider office of the preauthorization determination decision. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Requirements

• Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license in applicable state(s) required.

Nice To Haves

• NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States and current Puerto Rico Nursing Board license.
• BA/BS degree preferred.
• Advanced understanding of medication indications and side effects is strongly preferred.
• Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
• Previous utilization and/or quality management and/or call center experience preferred.
• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.

Responsibilities

• Conduct clinical medication reviews requiring advanced nursing assessment and critical thinking.
• Analyze claims and medication history to identify risks and recommend safe, evidence-based alternatives.
• Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
• Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
• Follows-up to obtain additional clinical information.
• Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees