Clinical Review Nurse I-1
Elevance Health

Responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

Primary duties may include, but are not limited to:

• Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
• Applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care.
• Adapts to a wide variety of medical review topics and multiple Medicare lines of business to include Part A, Part B, and DME.
• Articulates clearly with other clinicians to include medical doctors, nurses, and support personnel via teleconference education sessions.

Qualifications:

Minimum Qualifications:

• Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license required.

Preferred Qualifications:

• Excellent Communication Skills.
• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
• Must have high speed internet and capability of a wired connection to meet equipment requirements.
• Working experience with Microsoft Outlook, Word, and Excel.
• Working knowledge of Medicare rules and regulations a plus.

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