Nurse Reviewer II

Overview

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. Per policy, candidates not within a reasonable commuting distance from the posting location(s) may not be considered unless an accommodation is granted as required by law.

A proud member of the Elevance Health family of brands Carelon Health (formerly Care More 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)

Location(s): California, Chicago, Minnesota

Job Title: Nurse Reviewer II

Job Description: 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 non-routine issues. Conducts medical necessity clinical screenings of preauthorization requests to assess medical necessity of diagnostic imaging procedures, out-of-network services, and appropriateness of treatment.

Primary duties may include but are not limited to:

• Conducts initial medical necessity clinical screening and determines if initial clinical information meets medical necessity criteria or requires additional medical necessity review.
• Conducts initial medical necessity review of exception preauthorization requests for services outside 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

Requires an AS in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, and a 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.

• Knowledge of Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO, and POS plans (strongly preferred).
• BS in nursing preferred.
• Proficiency in Microsoft Office Products is preferred

For candidates working in person or virtually in the locations listed, the salary range for this position is $38.75 to $63.42 per hour. Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contributions (all benefits subject to eligibility requirements). The salary offered is based on a number of legitimate non-discriminatory factors set by the Company.

Job Level: Non-Management, Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED >
Licensed Nurse

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable federal, state or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Required Experience: IC