Elevance Health - Denison, TX
posted about 2 months ago
Full-time - Entry Level
Denison, TX
11-50 employees
Insurance Carriers and Related Activities
About the position
The Clinical Review Nurse I at Elevance Health is responsible for reviewing Medicare claims to determine if they meet the necessary benefits for members. This role involves applying clinical knowledge to assess the validity of claims, ensuring compliance with medical policies, and collaborating with other healthcare professionals. The position is primarily virtual, with flexible working hours, and requires a strong understanding of Medicare regulations and clinical practices.
Responsibilities
- Assess the necessity and reasonableness of items supplied in valid claims using medical policy and other materials.
- Apply clinical knowledge to ensure services/items billed are reasonable and necessary, supported by national and local policies.
- Adapt to various medical review topics and multiple Medicare lines of business including Part A, Part B, and DME.
- Communicate effectively with other clinicians via teleconference education sessions.
Requirements
- Associate's degree in nursing and a minimum of 1 year of clinical experience, or equivalent education and experience.
- Current unrestricted RN license required.
Nice-to-haves
- Bachelor's degree in nursing preferred.
- Ability to comprehend medical policy and criteria to articulate health information strongly preferred.
- Medical Review experience is a plus.
- Working experience with Microsoft Outlook, Word, and Excel.
- Working knowledge of Medicare rules and regulations is a plus.
- High-speed internet and capability of a wired connection to meet equipment requirements.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical, dental, and vision insurance
- Short and long-term disability benefits
- 401(k) with matching
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
