RN Nurse Reviewer I - CA

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RN Nurse Reviewer I - California

Location: Virtual - This role enables associates to work virtually full-time with the exception of required in-person training sessions (when indicated) providing maximum flexibility and autonomy. This approach promotes productivity supports work-life integration and ensures essential face-to-face onboarding and skill development.

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.

Work Shift: Monday - Friday 8:00 am (PST) to 5:00 pm (PST) and with occasional weekend coverage.

The RN Nurse Reviewer I is responsible for conducting preauthorization out of network and medical necessity reviews for post-acute admissions and continued stay requests by utilizing appropriate policies clinical guidelines and departmental operational processes. Collaborates with healthcare providers to promote the most appropriate highest quality and effective use of post-acute settings inclusive of Skilled Nursing Facility (SNF) Inpatient Rehabilitation Facility (IRF) and Long Term Acute Care Hospital (LTACH) 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 non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical reviews of preauthorization and continued stay requests to assess the medical necessity of post-acute confinements out of network services and appropriateness of continued treatment.

How you will make an impact:

• Conducts initial medical necessity clinical review 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 members network.

• Notifies ordering physician or rendering service provider office of the preauthorization determination decision.

• Follows-up to obtain additional clinical information.

• Ensures proper documentation provider communication and compliance adherence 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; or any combination of education and experience which would provide an equivalent background.

• Current active unrestricted RN license in the state of California is required.

Preferred Skills Capabilities and Experiences:

• Familiarity with Utilization Management Guidelines ICD-10 and managed health care including HMO PPO and POS plans preferred.

• BA/BS degree preferred.

• Previous utilization and/or quality management experience preferred.

• Open to obtaining RN licensure in other states such as Colorado and Nevada.

For candidates working in person or virtually in the below location(s) the pay range for this specific position is $36.28/hr. to $54.42/hr.

Locations: California

In addition to your salary Elevance Health offers benefits such as a comprehensive benefits package incentive and recognition programs equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of 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.

*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location work experience education and/or skill level. Even within the range the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned vested and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus commission benefits or any other form of compensation and benefits that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Companys sole discretion consistent with the law.

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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 market-competitive 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.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 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.