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Clinical Review Nurse, I

Anthem Blue Cross & Blue Shield

Anthem Blue Cross & Blue Shield

Virginia, USA · East Syracuse, NY, USA · Syracuse, NY, USA · Hingham, MA, USA · Denison, TX, USA · Harrisburg, PA, USA · Pennsylvania, USA · Harrisburg, PA, USA · Cincinnati, OH, USA · Ohio, USA · Shelbyville, KY, USA · Kentucky, USA · shelbyville, in, usa · Baltimore, MD, USA · Maryland, USA · Baltimore, MD, USA · South Portland, ME, USA · Portland, OR, USA
Posted on Saturday, September 16, 2023

Position Title:

Clinical Review Nurse, I

Job Description:

National Government Services is a proud member of Elevance Health Companies, Inc. family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

Locations: Indianapolis, IN, South Portland, ME, Baltimore, MD, Hingham, MA, Syracuse, NY, Cincinnati, OH, Harrisburg, PA, Shelbyville, KY or Denison, TX.

Elevance Health supports a hybrid workplace model with pulse point sites (major offices) used for collaboration, community, and connection. This position can be primarily virtual, however will be based within 50 miles of a pulse point site listed above.

Shift: Monday - Friday 8 am - 4:30 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.

How you will make an Impact:

  • 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.

  • Adapts to a wide variety of medical review topics in Part A appeals.

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 FGS (Federal Government Services) division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States for at least three of the past five years.

Preferred Skills, Capabilities, and Experience:

  • BS in nursing preferred.

  • The ability to comprehend medical policy and criteria to clearly articulate health information is strongly preferred.

  • Medicare experience preferred.

  • Medical Review experience preferred.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $61,920 to $111,456.

Locations: New York.

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 earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

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, providing various levels of flexibility while also ensuring that associates have opportunities to connect in-person. Unless in a designated virtual-eligible role and 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 – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.