Job Description

Anticipated End Date

2025-11-13

Position Title

Nurse Reviewer I

Job Description

Nurse Reviewer I

A proud member of the Elevance Health family of companies, Carelon Medical Benefits Management, formerly AIM Specialty Health, is a benefit?management leader in Illinois. Our platform delivers significant cost?of?care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.

Virtual

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.

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 Hours

Monday through Friday, 9:30AM - 6PM (CST).

Responsibilities

• 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 non?routine reviews.
• Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization requests to assess 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.
• Follows?up 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.
• Current unrestricted RN license in applicable state(s) required.

Preferred Skills, Capabilities, and Experiences

• Familiarity with Utilization Management Guidelines, ICD?9 and CPT?4 coding, and managed healthcare including HMO, PPO and POS plans strongly preferred.
• BA/BS degree preferred.
• Previous utilization and/or quality management and/or call center experience preferred.
• Previous Muscular Skeletal experience preferred.

Salary

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $33.12 p/h to $52.05 p/h.

Locations

Illinois and Maryland.

Benefits

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.

Job Level

Non?Management Non?Exempt

Job Family

MED > Licensed Nurse

Recruitment Notice

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.

Other Information

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.

Hybrid Workforce Strategy

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.

Health and Vaccination Policy

Elevance Healths health of our associates and communities is a top priority. 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.

Equal Opportunity Statement

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 elevancehealthjobssupport@elevancehealth.com 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.

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Job Tags

Full time, Work experience placement, Work at office, Local area, Monday to Friday, Shift work, 1 day per week,

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