Clinical Review Nurse I

Elevance Health

. Review claims and make complex medical determinations regarding whether claims meet the member’s benefits.

Posted 10/9/2026full-timeUnited StatesJuniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical claims review and determination, with a strong understanding of medical policy and criteria. Holds a current RN license and possesses clinical experience, ensuring compliance with federal program requirements and sensitive data handling protocols.

Highest-signal resume keywords

RN LicenseClinical ExperienceMedical ManagementUtilization ReviewMedical Policy Comprehension

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ReviewMedical DeterminationAssessment of NecessityData Handling ComplianceHealth Information Articulation

Soft Skills

CommunicationAttention to DetailAnalytical Thinking

Certifications & Qualifications

AS in NursingBS in Nursing (Preferred)

Industry Keywords

Federal ProgramsWellpoint FederalElevance HealthGovernment Business Division PoliciesCOVID-19 Vaccination Requirement

About the role

Key responsibilities & impact

Review claims and make complex medical determinations regarding whether claims meet the member’s benefits.
Assess the necessity and reasonableness of items supplied in valid claims.
Use medical policy and other materials to evaluate claims.
Provide virtual full-time work except for required in-person training sessions.
Complete face-to-face onboarding and skill development.
Work Monday through Friday during designated hours.
Support federal programs through Wellpoint Federal, a subsidiary of Elevance Health.

Requirements

What you’ll need

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.
Foreign national applicants must meet the residency requirement of living 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.
Medical management or Utilization Review experience preferred.
BS in nursing preferred.
May be subject to more stringent and frequent background checks and/or government clearances.
Must follow sensitive data handling instructions and Government Business Division policies, procedures, and guidelines.
Certain patient/member-facing roles require vaccination against COVID-19 and Influenza, unless an acceptable explanation is provided.
Must work within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law.
Monday through Friday availability, 8 am–5 pm EST based on time zone, with some flexibility.

Benefits

Comp & perks

$3500 sign-on bonus
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) + match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Virtual work flexibility
Required in-person training sessions
Potential accommodation for residency requirement under applicable law