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Clinical Review Nurse I – Medicare Part B
Elevance Health. Review claims and make medical determinations regarding 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 medical claims review, applying medical policies and criteria to make informed decisions. Strong communication skills are essential for conveying medical review outcomes clearly and concisely.
Highest-signal resume keywords
RN LicenseClinical ExperiencePart B Medicare ExperienceClaims Review ExperienceMedical Coding Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical ReviewClaims AssessmentBasic Math CalculationsClinical ReviewMedical Policy Comprehension
Soft Skills
Clear CommunicationConcise Decision-Making
Certifications & Qualifications
Coding Certification
Industry Keywords
Part B Nurse ClaimsSurgical ServicesICU ExperienceBackground ChecksSensitive Data Handling
About the role
Key responsibilities & impact- Review claims and make 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 conduct clinical reviews
- Apply criteria effectively to make informed medical review decisions
- Communicate medical review decisions clearly and concisely
- Complete required in-person training sessions and essential face-to-face onboarding and skill development
Requirements
What you’ll need- AS 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
- Foreign national applicants must have lived in the United States at least three of the past five years
- Ability to comprehend medical policies and apply criteria effectively
- Ability to communicate medical review decisions clearly and concisely
- Proficient in basic math calculations with percentages
- BS in nursing is preferred
- Part B Medicare experience is strongly preferred
- Prior experience with claims review of Medicare is preferred
- Coding certification or experience with medical coding is a plus
- Part B Nurse Claims experience is strongly preferred
- Experience in surgical services and ICU is strongly preferred
- May be subject to stringent and frequent background checks and/or government clearances, role-specific training, monitoring, and sensitive data handling requirements
Benefits
Comp & perks- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short and 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
- COVID-19 and Influenza vaccination coverage/requirement for certain roles