A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

Nurse Reviewer I

Training Hours: M-F, 8 AM-4 PM CST

Working hours: M-F, 8hr day shift, Flexible hours between 7a-7p CST

Locations: Costa Mesa, CA; Palo Alto, CA; Walnut Creek, CA; Woodland Hills, CA; Denver, CO; Wallingford, CT; Washington, DC; Wilmington, DE; Miami, FL; Tampa, FL; Atlanta, GA; Midland, GA; West Des Moines, IA; Chicago-Willis Tower, IL; Indianapolis, IN; Louisville, KY; Metairie, LA; Hanover, MD; South Portland, ME; Gilbert, MN; Mendota Heights, MN; St. Louis, MO; Cary, NC; Winston Salem, NC; Lincoln, NE; Manchester, NH; Iselin, NJ; Morristown, NJ; Las Vegas, NV; Latham, NY; Middletown, NY; New York City, NY; Cincinnati, OH; Columbus, OH; Mason, OH; Seven Hills, OH; Smithfield, RI; Nashville, TN; Houston, TX; Grand Prairie, TX; Norfolk, VA; Richmond, VA; Roanoke, VA; Seattle, WA; Waukesha, WI; or Charleston, WV.

Reasonable proximity (1-hour commute and a 50-Mile radius) to ONE of the Elevance Health major offices in the cities listed above is required.

The Nurse Reviewer I is 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 request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

How you will make an impact:

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

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.

Preferred Skills, Capabilities, and Experiences

• Home healthcare experience highly preferred.

• Familiarity with Utilization Management Guidelines, ICD-10 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.

• Computer knowledge, efficient typing skills.

• Proficient in Microsoft Office suite (Teams, Outlook, Word, Excel).

• Comfortable with remote work.

• Utilization Management experience highly preferred.