Clinical Review Nurse

Clinical Review Nurse I (US)

Location:

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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.

Hours:

Monday through Friday 8 am - 5 pm EST/CST.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The Clinical Review Nurse I - Medicare Part A 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. This position is also responsible for adapting to a wide variety of medical review topics in Part A appeals.

Ability to articulate clearly with other clinicians to include medical doctors, nurses, and support personnel is required. Responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

• Conduct investigations and reviews of members and provider grievances and appeals.
• Assess the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
• Generate appropriate written correspondence to providers, members, and regulatory entities.
• Ensure that appeals and grievances are resolved timely to meet regulatory time frames.

• 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.

• BS in nursing preferred.
• Part A Home Health and Hospice claim review experience preferred.
• Strong computer skills preferred.
• Experience with MAS or other CMS mainframe system preferred.
• The ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions, while also communicating those decisions clearly and concisely preferred.
• Part A Medicare experience is strongly preferred.
• Prior experience with claims review of Medicare is preferred.
• Experience in surgical services and ICU is strongly preferred.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a sensitive position work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.

Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which…