Nurse Reviewer I
About The Position
Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the center—connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health. The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.
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.
- A 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, PPO and POS plans strongly preferred.
- BA/BS degree preferred.
- Previous utilization and/or quality management and/or call center experience preferred.
Responsibilities
- Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- 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.
- Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics.
Benefits
- Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
