RN Clinical Review Nurse I

Position Title: RN Clinical Review Nurse I

Clinical Review Nurse I

Location: This is a virtual eligible position. You should be within a reasonable distance of one of our eligible offices.

Hours: General business hours, Monday through Friday (your time zone). Hours are flexible.

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.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Clinical Review Nurse I 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.
• The clinical nurse reviewer will be responsible for reviewing and adjudicating claims.

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 Skills, Capabilities, and Experiences

• Home Health or Hospice is very strongly preferred.
• Knowledge of Medicare guidelines preferred.
• BS in nursing preferred.
• Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse