Nurse Reviewer Associate
| Company | Elevance Health |
|---|---|
| Location | Las Vegas, NV, USA, Houston, TX, USA, Des Moines, IA, USA, Newport Beach, CA, USA, Canoga Park, Los Angeles, CA, USA, Chicago, IL, USA, Gilbert, MN, USA, St. Louis, MO, USA, Metairie, LA, USA, Walnut Creek, CA, USA, Grand Prairie, TX, USA, Meridian, ID, USA, Mendota Heights, MN, USA |
| Salary | $27.47 – $52.06 |
| Type | Full-Time |
| Degrees | Associate’s |
| Experience Level | Junior, Mid Level |
Requirements
- Requires AS in nursing.
- Current unrestricted RN license in applicable state(s) required.
Responsibilities
- Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits.
- Receives preauthorization requests from front-line intake.
- Conducts initial medical necessity clinical screening.
- Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- Conducts initial medical necessity review of out of network 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.
- Documents the results of the initial clinical review and determination in the precertification computer system.
- Maintains confidentiality of patient and provider specific information.
- Develops telephone service standards to meet departmental performance metrics.
Preferred Qualifications
- BS in nursing preferred.
- Familiarity with managed health care programs including HMO, PPO, and POS and with ICD-9 and CPT 4 coding preferred.