Clinical Review Nurse I
Elevance Health

Job Info

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Clinical Review Nurse I - Medicare Part A & B

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 or CST. Hours are flexible.

The Clinical Review Nurse I is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

How you will make an impact:

• 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 including medical doctors, nurses, and support personnel via teleconference education sessions.
  

Minimum Requirements:

• 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.
  
• This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States at least three of the past five years
  

Preferred Skills, Capabilities, and Experiences:

• BS in nursing preferred.
  
• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
  
• Medical Review experience is a plus.
  
• Working experience with Microsoft Outlook, Word, and Excel.
  
• Working knowledge of Medicare rules and regulations is a plus.
  
• Must have high-speed internet and the capability of a wired connection to meet equipment requirements.
  

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role-specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

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