Nurse Reviewer

Location: This role enables associates to work virtually full‑time, except for required in‑person training sessions, providing maximum flexibility and autonomy. 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.

Work Hours: Monday – Friday (11:30 AM – 8:00 PM Central) with rotating weekends (8:00 AM – 12:00 PM).

Position: Nurse Reviewer I – responsible for conducting preauthorization, out‑of‑network, and appropriateness reviews for diagnostic imaging services using appropriate policies, clinical and departmental guidelines. Collaborates with healthcare providers and members to promote the most appropriate, highest quality and effective use of diagnostic imaging, ensuring quality member outcomes and optimizing member benefits. Works on routine reviews with limited or no prior medical review experience.

Partners with senior colleagues for non‑routine reviews and learns to conduct medical necessity screenings through experience and mentoring.

• Conduct initial medical necessity clinical screening and determine if presented clinical information meets medical necessity criteria or requires additional review.
• Review exception preauthorization requests for services requested outside of the client health plan network.
• Notify ordering physician or rendering service provider office of the preauthorization determination decision.
• Follow up to obtain additional clinical information.
• Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics.
• Other duties as assigned.

Requires an Associate’s Degree in Nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting, or a 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 that provides an equivalent background. Current unrestricted RN license in applicable state(s) required.

• Familiarity with Utilization Management Guidelines.
• ICD‑9 and CPT‑4 coding; managed health care experience with HMO, PO and POS plans.
• BA/BS degree.
• Previous utilization and/or quality management and/or call center experience.
• Proficiency in Microsoft Office Products.

Salary Range (Hour): $34.69 – $54.41 (depending on location, experience, education and skill level) for positions in California, Illinois, and Minnesota.

Benefits: Comprehensive benefits package including health, dental, vision, short‑term and long‑term disability, 401(k) with company match, equity stock purchase plan, incentive and recognition programs, and wellness resources. Eligibility subject to company policies.

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 elevancehealthj for assistance.