Nurse Reviewer

Nurse Reviewer I 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. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development.

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

The Nurse Reviewer I is responsible for conducting pre‑authorization, out‑of‑network, and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. The role 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. The position works on reviews that are routine having limited or no prior 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 the reviewer learns to conduct medical necessity clinical screenings of pre‑authorization requests to assess the medical necessity of diagnostic imaging procedures, out‑of‑network services, and appropriateness of treatment.

• Conduct initial medical necessity clinical screening and determine if initial clinical information presented meets medical necessity criteria or requires additional review.
• Conduct initial medical necessity review of exception pre‑authorization requests for services requested outside of the client health plan network.
• Notify ordering physician or rendering service provider office of the pre‑authorization 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 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.
• 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.
• BA/BS degree.
• Previous utilization and/or quality management and/or call center experience.
• Proficiency in Microsoft Office Products.

For candidates working in person or virtually in the below locations, the salary range for this specific position is $34.69 to $54.41 (hourly). Location(s):
California, Illinois, Minnesota.

An all‑inclusive benefits package including incentive and recognition programs, equity stock purchase and 401(k) contribution (subject to eligibility). The salary offered for this position is based on 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.

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, and local laws.

Applicants who require accommodation to participate in the job application process may contact elevancehealthj 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.