Nurse Reviewer I - Virtual Role with Hybrid Work Model - Diagnostic Imaging Expertise Required

Transforming Healthcare through Compassionate Care and Innovative Solutions At Elevance Health, we're on a mission to make healthcare simpler and improve lives. As a Fortune 25 company with a rich history in the healthcare industry, we're seeking talented professionals like you to join our team. As a Nurse Reviewer I, you'll play a critical role in ensuring the highest quality and most effective use of diagnostic imaging services for our members. About the Role We're excited to offer a unique opportunity to work in a virtual role with a hybrid work model, allowing you to balance remote work with time in our office. As a Nurse Reviewer I, you'll be responsible for conducting preauthorization, out-of-network, and appropriateness of treatment reviews for diagnostic imaging services. You'll collaborate with healthcare providers and members to promote the most appropriate and effective use of diagnostic imaging, ensuring quality member outcomes and optimizing member benefits. Key Responsibilities Conduct initial medical necessity clinical screenings and determine if initial clinical information presented meets medical necessity criteria or requires additional review. Conduct initial medical necessity reviews of exception preauthorization requests for services requested outside of the client health plan network. Notify ordering physicians or rendering service provider offices of preauthorization determination decisions. Follow up to obtain additional clinical information and ensure proper documentation, provider communication, and telephone service per department standards and performance metrics. Collaborate with more senior colleagues to complete non-routine reviews and learn to conduct medical necessity clinical screenings. Essential Qualifications To be successful in this role, you'll need: An Associate's degree in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or a minimum of 1 year of prior utilization management, medical management, and/or quality management, and/or call center experience. A current, unrestricted RN license in the applicable state(s). Preferred Skills and Experiences We're looking for candidates with: Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed healthcare, including HMO, PPO, and POS plans. A Bachelor's degree in a relevant field. Previous utilization and/or quality management and/or call center experience. Knowledge of Microsoft Office. What We Offer At Elevance Health, we offer a comprehensive benefits package, including: A competitive salary range of $35.35 to $44.18. Incentive and recognition programs. Equity stock purchase and 401(k) contribution. Medical, dental, vision, short-term, and long-term disability benefits. Paid holidays, Paid Time Off, and incentive bonus programs. Wellness programs and financial education resources. Career Growth and Development As a Nurse Reviewer I, you'll have opportunities for career growth and professional development. You'll work with a supportive team and have access to training and mentorship to help you succeed. Our hybrid work model allows you to balance work and personal life, and our comprehensive benefits package supports your overall well-being. Our Culture and Values At Elevance Health, we're committed to creating a culture that advances our strategy and leads to personal and professional growth for our associates. Our values and behaviors are the root of our culture, and we're dedicated to making a positive impact on our members and the communities we serve. Why Join Us? If you're a compassionate and innovative healthcare professional looking for a new challenge, we encourage you to apply. As a Nurse Reviewer I, you'll play a critical role in transforming healthcare and improving lives. You'll have the opportunity to work with a talented team, develop your skills, and grow your career. How to Apply If you're ready to join our team and make a difference in the lives of our members, please submit your application today. We're excited to hear from you and discuss this opportunity further. Equal Employment Opportunity 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 or condition protected by applicable federal, state, or local laws. Additional Information Elevance Health operates in a Hybrid Workforce Strategy, and 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 as part of the hiring process. Candidates must reside within 50 miles or a 1-hour commute each way of a relevant Elevance Health location. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Apply for this job