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Nurse Reviewer I (US)

Anticipated End Date:

2025-04-22

Position Title:

Nurse Reviewer I (US)

Job Description:

Nurse Reviewer I

Location: Elevance Health supports a hybrid workplace model with PulsePoint sites (major office) used for collaboration, community, and connection. This position will be primarily virtual, however will be based within 50 miles of a PulsePoint site.

The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging 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 screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

How you will make an impact:

  • Conducts initial medical necessity clinical screening 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 client health plan 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 telephone service 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, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

  • Current unrestricted RN license in applicable state(s) required.

  • Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.

  • BA/BS degree preferred.

  • Previous utilization and/or quality management and/or call center experience preferred.

For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $34.69/hr to $54.41/hr

Locations: California & Illinois

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 Non-Exempt

Workshift:

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.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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. Unless 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 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Average salary estimate

$92500 / YEARLY (est.)
min
max
$72000K
$113000K

If an employer mentions a salary or salary range on their job, we display it as an "Employer Estimate". If a job has no salary data, Rise displays an estimate if available.

What You Should Know About Nurse Reviewer I (US), elevancehealth

As a Nurse Reviewer I at Elevance Health, based in vibrant Chicago, IL, you'll find this role exciting and impactful. Elevance Health prides itself on fostering a hybrid workplace model, which means you'll enjoy the flexibility of working virtually while maintaining an essential connection to a community around you. In this position, you'll conduct vital preauthorization reviews for diagnostic imaging services, which means applying your clinical insights to ensure members receive only the most appropriate and high-quality care. You'll collaborate closely with healthcare providers to optimize the use of diagnostic imaging, helping to ensure that all treatments align with member benefits and medical necessity guidelines. Even though the reviews you will start with are routine and may require guidance from more experienced colleagues, the learning curve is perfect for those who crave mentorship and growth. As you grow in this role, you'll take on more complex reviews and develop sharp clinical screening skills. Your experience in nursing, whether in a clinical or managed care setting, will be invaluable, and you'll be part of a team committed to quality outcomes for our members. We believe in a culture of continuous improvement and support, and your contributions will directly impact lives and communities. If you're ready to embrace this challenge and work alongside passionate professionals in the healthcare space, Elevance Health is the place to thrive!

Frequently Asked Questions (FAQs) for Nurse Reviewer I (US) Role at elevancehealth
What are the main responsibilities of a Nurse Reviewer I at Elevance Health?

As a Nurse Reviewer I at Elevance Health, your main responsibilities will focus on conducting preauthorization and treatment appropriateness reviews for diagnostic imaging services. You'll evaluate medical necessity criteria, collaborate with healthcare providers, and ensure documentation meets departmental standards. This role is essential in promoting high-quality care and optimal member outcomes.

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What qualifications do I need to apply for the Nurse Reviewer I position at Elevance Health?

To qualify for the Nurse Reviewer I position at Elevance Health, you should have an Associate's degree in nursing and at least three years of clinical nursing experience or one year of utilization management or related experience. A current unrestricted RN license is required, and familiarity with healthcare management guidelines is preferred for success in the role.

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Can I work remotely as a Nurse Reviewer I at Elevance Health?

Yes, the Nurse Reviewer I role at Elevance Health typically allows for remote work, as long as you reside within 50 miles of a PulsePoint site. The company emphasizes collaboration and connection, so you'll have the flexibility to work virtually while still being part of a supportive team environment.

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What tools and resources will I have access to as a Nurse Reviewer I at Elevance Health?

As a Nurse Reviewer I at Elevance Health, you'll have access to a range of tools and resources designed to facilitate your work. This includes clinical guidelines, departmental policies, and support from senior colleagues to help you successfully navigate complex review processes.

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What benefits does Elevance Health offer to its Nurse Reviewer I employees?

Elevance Health offers a comprehensive benefits package for its Nurse Reviewer I employees. This includes competitive salaries, merit increases, health benefits, retirement plans, wellness programs, and stock purchase options. These benefits support our commitment to employee well-being and job satisfaction.

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Common Interview Questions for Nurse Reviewer I (US)
How would you handle a situation where you disagree with a physician's treatment decision?

In handling disagreements with a physician's treatment decision, I would first ensure to communicate openly and respectfully. Gathering relevant clinical data and presenting my perspective based on established guidelines would be key. Ultimately, I seek to understand the physician’s reasoning while advocating for the best member outcomes.

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Can you describe your experience with utilization management?

I have gained experience in utilization management through my previous nursing roles where I evaluated treatment plans and ensured compliance with medical necessity criteria. This involved close collaboration with healthcare teams and ongoing education on guidelines, which I believe will translate well into the Nurse Reviewer I position at Elevance Health.

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What strategies would you use to stay organized when reviewing multiple cases?

To stay organized while reviewing multiple cases, I prioritize using a systematic approach, like creating checklists for each case's requirements. Additionally, utilizing digital tools for tracking the status and documentation helps manage workload efficiently and ensures timely follow-ups.

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How do you ensure accurate documentation in your reviews?

To ensure accurate documentation, I utilize a thorough verification process whereby I cross-check the clinical information with the criteria for medical necessity. I believe accurate documentation is essential for maintaining compliance and supporting subsequent reviews or audits.

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What do you consider when assessing the medical necessity of procedures?

When assessing medical necessity, I consider the clinical information presented, alignment with established guidelines, and the patient's medical history. It's important to evaluate whether the proposed procedure effectively addresses the patient's condition while adhering to insurance criteria.

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Describe a time when you had to learn a new guideline or policy quickly. How did you manage that?

In a previous role, I had to quickly adapt to new insurance utilization guidelines. I devoted time to studying the materials thoroughly and discussed with colleagues for clarification. Regular review sessions and practice cases helped me gain confidence in applying the new guidelines efficiently.

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How would you approach a preauthorization request that is outside of standard protocol?

For a preauthorization request outside of standard protocol, I would first gather all pertinent information to assess the rationale for the request. Consulting with senior reviewers and utilizing the exceptions framework is vital, ensuring a balanced approach for both the patient and the healthcare provider.

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What makes you a good fit for the Nurse Reviewer I role at Elevance Health?

My clinical background, strong analytical skills, and dedication to improving member outcomes make me a good fit for the Nurse Reviewer I role. I thrive in collaborative environments and am eager to contribute positively to Elevance Health’s mission of simplifying healthcare.

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How do you prioritize your tasks when under pressure?

When faced with high-pressure situations, I assess urgent tasks and classify them based on deadlines and the potential impact on member care. Keeping a flexible mindset allows me to adjust my priorities as needed while maintaining focus on the tasks at hand.

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Tell me about your experience working in a hybrid or remote environment.

In my previous positions, I frequently worked in hybrid settings, which taught me the importance of effective communication and collaboration using digital tools. I enjoy the balance of remote focus time and the connection of in-person meetings, and I adapt well to this flexible working model.

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EMPLOYMENT TYPE
Full-time, hybrid
DATE POSTED
April 17, 2025

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