Nurse Reviewer I

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Job Description:

Nurse Reviewer I

Location: Tampa FL

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 nonroutine 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.

• Followsup 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 ICD9 and CPT4 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.

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Workshift:

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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 marketcompetitive 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 1hour 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/memberfacing roles to become vaccinated against COVID19 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 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.