Elevance Health clinical review nurse Sr-1 in Bridgewater, Massachusetts
clinical review nurse Sr-1
Job Family: Medical and Clinical
Type: Full time
Date Posted:Jul 28, 2022
Req #: JR10699
NY, East Syracuse
Rhode Island, Rhode Island
New York, New York
New Hampshire, New Hampshire
National Government Services is a proud member of Elevance Health family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.
Shift: Monday - Friday, 9 am - 5:30 pm EST
How you will make an Impact:
The Clinical Review Nurse Sr is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.
Responsible for coordinating and overseeing the work of the case managers review or utilization nurses.
Primary duties may include but are not limited to:
Responds to the most complex medical issues.
May participate in or cross-functional teams projects and initiatives process improvement activities.
May serve as departmental liaison to other areas of the business.
Serves as a resource to case managers review nurses or utilization nurses.
Comprehends complex policies and medical criteria as it pertains to member.
Travel is required monthly.
Requires AS in nursing and minimum of 5 years of clinical experience; or any combination of education and experience which would provide an equivalent background.
Current unrestricted RN license required. BS in nursing preferred.
This position is part of our FGS (Federal Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.
Preferred Skills, Capabilities, and Experiences:
BS in nursing preferred.
Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
Medicare hospice knowledge or understanding of hospice Medicare coverage.
Skilled nursing facility experience.
Excellent understanding of hospice and SNF benefits OR willingness to learn.
Experience with provider education and medical review.
Ability to identify changing priorities and address priorities.
Ability to interpret Medicare regulations.
Excellent communication skills.
Ability to travel 1 week a month (subject to change).
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. 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 email@example.com for assistance.
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