Nurse Reviewer II
About The Position
Nurse Reviewer II 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. 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 brands, Carelon Health (formerly CareMore Health) offers clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery. Work Hours: Monday - Friday (9:30 AM -6:00 PM Central) The Nurse Reviewer II is responsible for collaborating 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 of moderate complexity requiring guidance by more senior colleagues and/or management on only non-routine issues. Conducts 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. How you will make an impact
Requirements
- Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting and minimum of 1 year of prior utilization, 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
- Knowledge of Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.
- BS in nursing preferred.
- Proficiency in Microsoft Office Products is 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.
- Mentors and coaches new employees in the nurse review process.
- Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
- Follows-up as necessary to obtain additional clinical information as applicable.
- Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
- Other duties as assigned
Benefits
- In addition to your salary, 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).
- 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
