Clinical Review Nurse I

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. 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 as part of the hiring process. Candidates must reside within 50 miles or 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. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs. Location: This is a virtual position and preferred candidates reside within 50 miles of an Elevance Health PulsePoint location. Hours: Monday through Friday 8 am - 5 pm EST. The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries and for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare.

Conducts investigations and reviews of member and provider grievances and appeals. Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials. Generates appropriate written correspondence to providers, members, and regulatory entities. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.