RN Clinical Review Nurse I
About The Position
Wellpoint Federal, a subsidiary of Elevance Health, provides healthcare services and solutions in support of federal programs. The Clinical Review Nurse I reviews claims and makes medical determinations about whether they meet the benefits carried by a member. The role assesses the necessity and reasonableness of items supplied in a valid claim using medical policy and other materials, and reviews and adjudicates claims. This is a virtual-eligible role, with required in-person training sessions. Candidates must live within a reasonable commuting distance of an eligible office unless an accommodation is granted as required by law. Work hours are flexible during general business hours, Monday through Friday, in the employee’s time zone.
Requirements
- Associate degree in nursing and at least 1 year of clinical experience, or an equivalent combination of education and experience.
- Current unrestricted RN license.
- For this Wellpoint Federal division role, foreign national applicants must have lived in the United States for at least three of the past five years.
Nice To Haves
- Home Health or Hospice experience is very strongly preferred.
- Knowledge of Medicare guidelines is preferred.
- Bachelor of Science in nursing is preferred.
- Ability to comprehend medical policy and criteria and clearly articulate health information is strongly preferred.
Responsibilities
- Assess the necessity and reasonableness of items supplied in a valid claim using medical policy and other materials.
- Review and adjudicate claims.
- Make medical determinations as to whether a claim meets the benefits carried by the member.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short- and long-term disability benefits
- 401(k) with company match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
