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RN Clinical Review Nurse I
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 reviewing and adjudicating medical claims, with a strong understanding of Medicare guidelines and the ability to articulate health information clearly. Holds a current RN license and possesses clinical experience, particularly in Home Health or Hospice settings.
Highest-signal resume keywords
RN LicenseClinical ExperienceMedical Policy ComprehensionHome Health ExperienceMedicare Guidelines Knowledge
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Certifications & Qualifications
RN License
Industry Keywords
Claims ReviewMedical DeterminationsAdjudicationHome HealthHospiceMedicare Guidelines
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 using medical policy and other materials
- Review and adjudicate claims
- Work virtually full-time during general business hours, Monday through Friday, with flexible hours
- Attend required in-person training sessions
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
- Must have lived in the United States at least three of the past five years if a foreign national applicant
- Home Health or Hospice experience strongly preferred
- Knowledge of Medicare guidelines preferred
- BS in nursing preferred
- Ability to comprehend medical policy and criteria and clearly articulate health information strongly 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 match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Flexible hours
- Virtual full-time work arrangement
- Required in-person training sessions
- Vaccination support/requirements for certain patient/member-facing roles