The Clinical Review Nurse I is responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. This position 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.

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.

• Skilled nursing facility, inpatient, home health, and hospice experience helpful.

• Strong computer skills are helpful.

• Experience with MAS or other CMS mainframe systems is helpful.

• This position is also responsible for adapting 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 articulate health information clearly is strongly preferred.

• Medicare experience preferred.

• Medical Review experience preferred.

• Prior experience with claim review is preferred.

• The ability to articulate clearly with other clinicians including medical doctors, nurses, and support personnel is 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.