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Clinical Review Nurse I
Elevance Health. Review and make medical determinations as to whether claims meet the member's benefits .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reviewing and adjudicating medical claims, with a strong understanding of medical policy and Medicare guidelines. Holds a current RN license and possesses clinical experience to effectively assess claims and articulate health information.
Highest-signal resume keywords
RN LicenseClinical ExperienceMedical Policy ComprehensionMedicare Part B KnowledgeMedicare Guidelines Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Soft Skills
Clear Articulation of Health Information
Certifications & Qualifications
Associate Degree in Nursing
Industry Keywords
Claims AdjudicationMedical DeterminationsHealth InformationBenefit AssessmentIn-Person Training
About the role
Key responsibilities & impact- Review and make medical determinations as to whether claims meet the member's benefits
- Assess the necessity and reasonableness of items supplied in valid claims using medical policy and other materials
- Review and adjudicate claims
- Participate in required in-person training sessions and onboarding/skill development
Requirements
What you’ll need- Associate degree in nursing and minimum of 1 year of clinical experience; or any combination of education and experience providing an equivalent background
- Current unrestricted RN license required
- Must have lived in the United States at least three of the past five years
- Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred
- Medicare Part B knowledge preferred
- Knowledge of Medicare guidelines preferred
Benefits
Comp & perks- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) with employer match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work with flexible hours
- Required in-person training sessions
- Work-life integration and autonomy