RN Nurse Reviewer I - CA

Anticipated End Date:

2025-08-07

Position Title:

RN Nurse Reviewer I - CA

Job Description:

RN Nurse Reviewer I - California

Location: Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), 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 Shift: Monday - Friday, 8:00 am (PST) to 5:00 pm (PST) and with occasional weekend coverage.

The RN Nurse Reviewer I is responsible for conducting preauthorization, out of network and medical necessity reviews for post-acute admissions and continued stay requests by utilizing appropriate policies, clinical guidelines, and departmental operational processes. Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of post-acute settings inclusive of Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Long Term Acute Care Hospital (LTACH), to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical reviews of preauthorization and continued stay requests to assess the medical necessity of post-acute confinements, out of network services, and appropriateness of continued treatment.

How you will make an impact:

• Conducts initial medical necessity clinical review and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. 

• Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the members’ network. 

• Notifies ordering physician or rendering service provider office of the preauthorization determination decision. 

• Follows-up to obtain additional clinical information. 

• Ensures proper documentation, provider communication, and compliance adherence per department standards and performance metrics.

Minimum Requirements:

• Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management; or any combination of education and experience, which would provide an equivalent background. 

• Current, active, unrestricted RN license in the state of California is required.

Preferred Skills, Capabilities and Experiences:

• Familiarity with Utilization Management Guidelines, ICD-10 and managed health care including HMO, PPO and POS plans preferred. 

• BA/BS degree preferred. 

• Previous utilization and/or quality management experience preferred.

• Open to obtaining RN licensure in other states such as Colorado and Nevada.

For candidates working in person or virtually in the below location(s), the pay range for this specific position is $36.28/hr. to $54.42/hr. 

Locations: California

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. 

*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is ea