Nurse Reviewer I

Elevance Health • Walnut Creek, CA

369d • $35 - $44

About The Position

The Nurse Reviewer I position is a virtual role that requires candidates to be located within 50 miles of a Pulse Point. The schedule for this position is from 9:30 am to 6:00 pm PST, with the possibility of working weekends if necessary. New graduates are encouraged to apply for this role. The primary responsibility of the Nurse Reviewer I is to conduct preauthorization, out of network, and appropriateness of treatment reviews for diagnostic imaging services, utilizing appropriate policies, clinical and department guidelines. This role involves collaboration with healthcare providers and members to ensure the effective use of diagnostic imaging, promoting quality member outcomes and optimizing member benefits. The position requires working on routine reviews with limited previous medical review experience, while also partnering with more senior colleagues for non-routine reviews. Through mentoring and work experience, the Nurse Reviewer I will learn to conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures and out of network services.

Requirements

• 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 that provides an equivalent background.
• Current unrestricted RN license in applicable state(s) required.

Nice To Haves

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
• BA/BS degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.
• Knowledge in Microsoft Office.

Responsibilities

• Conduct initial medical necessity clinical screening and determine if initial clinical information meets medical necessity criteria or requires additional review.
• Conduct initial medical necessity review of exception preauthorization requests for services outside of the client health plan network.
• Notify ordering physician or rendering service provider office of the preauthorization determination decision.
• Follow up to obtain additional clinical information.
• Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics.

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid Time Off
• Medical, dental, vision benefits
• Short and long term disability benefits
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees