National Government Services is a proud member of Elevance Health's family of brands. Weadminister government contracts for Medicare and partner with the Centers forMedicare and Medicaid Services to transform federal health programs.
Location: This is a virtual position and preferred candidates reside within 50 miles of an Elevance Health PulsePoint location .
Hours: Monday through Friday 8 am - 5 pm EST or CST. Hours are flexible.
The Clinical Review Nurse II is responsible for reviewing and making more complex medical determinations as to whether a claim meets the benefits the member carries.
H ow you will make an impact:
Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy.
Minimum Requirements:
Requires AS in nursing and a minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license required.
This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants to 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.
The ability to comprehend medical policy and criteria to clearly articulate health information is strongly preferred.
Medicare Home Health or Hospice experience is a plus.
Prior experience with claim review of Medicare helpful.
If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role-specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.
