Experienced Remote Nurse Reviewer I (US) - Diagnostic Imaging Services and Utilization Management Specialist

Introduction to Elevance Health Elevance Health is a leading health company dedicated to improving lives and communities, making healthcare simpler, and driving positive change in the industry. As a Fortune 25 company with a rich history in healthcare, we are committed to providing high-quality services that meet the evolving needs of our members and the communities we serve. Our mission is built on a foundation of values and behaviors that prioritize the well-being of our associates, consumers, and the communities we touch. Job Overview We are seeking an experienced and skilled Nurse Reviewer I (US) to join our team, working remotely from one of our designated locations. As a Nurse Reviewer I, you will play a critical role in conducting preauthorization, out-of-network, and appropriateness of treatment reviews for diagnostic imaging services. Your expertise will help ensure that our members receive the most appropriate, highest quality, and effective care, optimizing their benefits and promoting positive health outcomes. Key Responsibilities Conduct thorough reviews of preauthorization requests, out-of-network services, and treatment plans to determine medical necessity and appropriateness of care. Collaborate with healthcare providers, members, and internal stakeholders to promote high-quality, effective, and efficient care. Work on routine reviews, with limited or no previous medical review experience, requiring guidance from senior colleagues and management as needed. Partner with senior colleagues to complete non-routine reviews, developing your skills and expertise in utilization management and medical necessity screenings. Conduct initial medical necessity clinical screenings, determining if initial clinical information meets medical necessity criteria or requires additional review. Notify ordering physicians or rendering service providers of preauthorization determination decisions, ensuring timely and effective communication. Follow up to obtain additional clinical information, ensuring that all necessary documentation is complete and accurate. Maintain proper documentation, provider communication, and telephone service, adhering to department standards and performance metrics. Essential Qualifications Associate's degree in nursing (AS) and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting. Alternatively, a minimum of 1 year of prior utilization management, medical management, and/or quality management, and/or call center experience, combined with relevant education and training. Current unrestricted RN license in applicable state(s) required. Preferred Qualifications Bachelor's degree in nursing (BS) or a related field preferred. Previous utilization and/or quality management and/or call center experience strongly preferred. Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care, including HMO, PPO, and POS plans. Knowledge of Microsoft Office and electronic health records (EHRs) preferred. Skills and Competencies Strong clinical knowledge and critical thinking skills, with the ability to analyze complex medical information and make informed decisions. Excellent communication and interpersonal skills, with the ability to collaborate with healthcare providers, members, and internal stakeholders. Ability to work independently and as part of a team, with a strong focus on quality, efficiency, and customer satisfaction. Strong organizational and time management skills, with the ability to prioritize tasks and manage multiple projects simultaneously. Career Growth and Development At Elevance Health, we are committed to supporting the growth and development of our associates. As a Nurse Reviewer I, you will have opportunities to develop your skills and expertise in utilization management, medical necessity screenings, and quality improvement. You will work closely with senior colleagues and management to receive guidance, mentorship, and support, helping you to advance your career and achieve your professional goals. Work Environment and Company Culture We operate in a hybrid workforce strategy, with a mix of remote and on-site work. As a remote worker, you will be required to work from home, with occasional visits to our offices as needed. Our company culture is built on a foundation of values and behaviors that prioritize the well-being of our associates, consumers, and communities. We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs, as well as comprehensive benefits, including medical, dental, vision, and 401(k) matching. Compensation and Benefits The salary range for this position is $31.26 to $42.79 per hour, depending on experience and location. In addition to your salary, we offer a comprehensive benefits package, including: Medical, dental, and vision coverage 401(k) matching and stock purchase plan Paid Time Off and paid holidays Incentive bonus programs Wellness programs and financial education resources Conclusion If you are a motivated and experienced nurse looking for a new challenge, we encourage you to apply for this exciting opportunity. As a Nurse Reviewer I at Elevance Health, you will have the chance to make a significant impact on the lives of our members, while developing your skills and expertise in utilization management and quality improvement. Join our team and take the first step towards a rewarding new role. How to Apply To apply for this position, please submit your application through our website. We look forward to receiving your application and exploring how you can contribute to our team. Apply for this job