Nurse Reviewer I Job at Elevance Health, Los Angeles, CA

aUNMQXJnR25YZzIxU25aK3FEMjRKQmp0Z1E9PQ==
  • Elevance Health
  • Los Angeles, CA

Job Description

Location: This is a Virtual role, Must be located within 50 miles of a Pulse Point Schedule: 9:30am-6:00pm, Rotating weekend shifts. 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 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. Primary duties may include, but are not limited to: 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: 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 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. Knowledge in Microsoft Office. For candidates working in person or remotely in the below location(s), the salary* range for this specific position is $33.81 to $44.18. Locations: Illinois, California, Maryland 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). #J-18808-Ljbffr Elevance Health

Job Tags

Work experience placement, Rotating shift,

Similar Jobs

AC Foods

Farm Manager Job at AC Foods

 ...Job Description Job Description Description: Position Summary: The Farm Manager- Oregon leads the growing operations by directing and overseeing the growing of blueberry crops. This position assures that all KPIs are accomplished using good farming practices... 

CoolSys

Journeyman 1-HVAC - Light Commercial Job at CoolSys

 ...advance your career while working with top-tier clients in the HVAC and refrigeration industry Responsibilities: Journeyman 1 - HVAC...  ...Journeyman 1 - HVAC Installation is responsible for installing commercial heating, ventilation, and air conditioning (HVAC) systems ,... 

CTS Complete Technical Services

Fire Protection Engineer Job at CTS Complete Technical Services

 ...Safety Engineer- Fire Location: Lake Charles, LA Description: The Safety Engineer Fire position provides engineering support on fire protection and safety systems to ensure compliance with corporate and regulatory requirements. The engineer will evaluate,... 

Ace Hotel New York

Community & Marketing Manager Job at Ace Hotel New York

Compensation Type: Yearly Highgate Hotels: Highgate is a premier real estate investment and hospitality management company widely recognized...  ...the industry. Highgate is the dominant player in U.S. gateway markets including New York, Boston, Miami, San Francisco and Honolulu,... 

Rocket Lab

iOS Engineer II - (Trust & Safety) Job at Rocket Lab

 ...lives. We believe in the power of movement to connect and drive people forward.Were seeking a Senior iOS Engineer to join our Trust and Safety engineering team. This team is responsible for developing features that foster a trustworthy environment on Strava by...