Clinical Review Nurse I

Anticipated End Date:

2025-09-13

Position Title:

Clinical Review Nurse I

Job Description:

Clinical Review Nurse I

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Work schedule:  Monday - Friday 8 - 4:30 pm EST.

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.

The Clinical Review Nurse is 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. 

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.

• 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 Qualifications:

• BS in nursing is a plus.

• 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.

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.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

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