Clinical Review Nurse I - Medicare Part B

Position Title: Clinical Review Nurse I - Medicare Part B

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Hours: Monday through Friday 8 am - 5 pm EST.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The Clinical Review Nurse I - Medicare Part B is responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.

How you will make an impact

• Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.

Minimum Requirements

• Requires AS in nursing and minimum of 1 year 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 Wellpoint Federal 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 Capabilities, Skills and Experiences

• BS in nursing is preferred.
• The ability to comprehend medical policies and apply criteria effectively to make informed medical review decisions, while also communicating those decisions clearly and concisely.
• Part B Medicare experience is strongly preferred.
• Prior experience with claims review of Medicare is preferred.
• Proficient in basic math calculations with percentages.
• Coding certification or experience with medical coding is a plus.
• Part B Nurse Claims is strongly preferred.
• Experience in surgical services and ICU is strongly preferred.

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.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $67,200 to $100,800.

Location(s): New York, Maine