Nurse Reviewer I

Elevance Health•Chicago, IL

9d•$36 - $56•Remote

About The Position

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 request to assess assessing 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.
Current, unrestricted RN license in either Illinois and/or California is 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.

Responsibilities

Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
Follows-up to obtain additional clinical information.
Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
Validating appeal requests.
Manage appeal requests that come via email, fax, mailed in letters, or via live line.
Opening and closing appeal requests following established appeal processes to maintain quality, turnaround time, and compliance requirements.
Outreach to providers with appeal process instructions.
Clinical review for the RBM and Surgical solution on a client specific basis.
Notifying providers and/or members of appeal decisions.
Maintain log of all appeal requests assigned to ensure completion, as needed.