[Hiring] Nurse Reviewer I @Elevance Health

Role Description

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. This role involves:

• Conducting initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
• Following up to obtain additional clinical information.
• Ensuring proper documentation, provider communication, and telephone service per department standards and performance metrics.
• Validating appeal requests.
• Managing appeal requests that come via email, fax, mailed 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.
• Maintaining a log of all appeal requests assigned to ensure completion, as needed.

Qualifications

• 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.

Requirements

• 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.

Benefits

• Comprehensive benefits package.
• Incentive and recognition programs.
• Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• Paid holidays and Paid Time Off.
• Medical, dental, and vision benefits.
• Short and long-term disability benefits.
• Life insurance.
• Wellness programs and financial education resources.