Nurse Reviewer

Virtual: This role enables associates to work virtually full-time, with the exception of 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.

Work policy and eligibility: 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.

Work schedule: Monday - Friday 9:30am - 6pm local time, with rotating weekends. (Saturday 8am-12pm CST, with a comp day during the week)

will be 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 routine reviews with 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.

How You Will Make An Impact

• 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.
• Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Minimum 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 applicable state(s) required.

Preferred Skills, Capabilities, and Experiences

• 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.
• RN Compact License is strongly preferred; CA RN License is also preferred.
• Experience in cardiology/radiology is preferred but not required.

Locations:
California.

Salary range:
The salary range for this position is $36.27 to $56.77 per hour, plus benefits as described below.

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities, and making healthcare simpler. We are a Fortune 25 company looking for leaders at all levels who are passionate about making an impact on our members and the communities we serve.

How We Work

We are creating a culture designed to advance our strategy and support personal and professional growth. We offer market-competitive total rewards including paid holidays, PTO, incentive programs, medical/dental/vision, disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed during the hiring process.

Vaccination policy: The health of our associates and communities is a top priority. New candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza; if not vaccinated, offers may be rescinded unless an acceptable explanation is provided. We follow all relevant federal, state and local laws.

Equal Employment Opportunity: Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by law. Accommodation requests during the application process may be directed to elevancehealthj Qualified…