Nurse Reviewer I

About the Role

The nursing team at Carelon is committed to providing high-quality care and support to members, and as a Nurse Reviewer I, you will be an integral part of this team. You will work closely with senior colleagues and management to complete non-routine reviews, and through mentoring and work experience, you will develop the skills and expertise to conduct medical necessity clinical screenings.

Carelon Global Solutions is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. The company puts people at the center, connecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together.

What You Will Do

• Conduct preauthorization reviews for diagnostic imaging services, utilizing appropriate policies, clinical, and department guidelines
• Collaborate with healthcare providers and members to promote the most appropriate, highest quality, and effective use of diagnostic imaging
• Work on reviews that are routine, with limited or no previous medical review experience, requiring guidance by more senior colleagues and/or management
• Partner with more senior colleagues to complete non-routine reviews
• Develop skills and expertise to conduct medical necessity clinical screenings of preauthorization requests
• Assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment
• Notify ordering physicians or rendering service provider offices of preauthorization determination decisions
• Follow up to obtain additional clinical information
• Ensure proper documentation, provider communication, and telephone service per department standards and performance metrics
• Conduct initial medical necessity clinical screenings and determine if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
• Conduct initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network

What We Are Looking For

• Associate's degree in nursing and a minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting
• Minimum of 1 year of prior utilization management, medical management, and/or quality management, and/or call center experience
• Current unrestricted RN license in applicable state(s) required
• Strong communication and collaboration skills
• Ability to work in a remote setting, with flexibility and autonomy
• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care, including HMO, PPO, and POS plans
• BA/BS degree preferred
• Previous utilization and/or quality management and/or call center experience preferred
• Knowledge of Microsoft Office

Nice to Have

• Experience working in a remote or virtual setting
• Familiarity with electronic health records and other healthcare technology
• Certification in utilization management or a related field
• Bilingual or multilingual skills

Benefits and Perks

• Competitive salary range
• Opportunities for professional growth and development
• Collaborative and dynamic work environment
• Flexible and autonomous work arrangement
• Access to advanced technology and resources
• Comprehensive benefits package, including health, dental, and vision insurance
• 401(k) or retirement savings plan
• Paid time off and holidays
• Remote work stipend or allowance

• Tip: Make sure to highlight your clinical nursing experience and education in your resume and cover letter, as these are key requirements for the role.
• To stand out, demonstrate your knowledge of Utilization Management Guidelines and ICD-9 and CPT-4 coding, as well as your experience with managed health care.
• During the interview process, be prepared to discuss your experience working in a fast-paced environment and your ability to make informed decisions with limited supervision.
• Consider creating a portfolio or examples of your work, such as case studies or reviews, to demonstrate your skills and expertise.
• When negotiating salary, be aware of the competitive salary range and benefits package offered by the company, and be prepared to discuss your expectations and requirements.
• Red flag: Be cautious of companies that do not provide clear information about the role, expectations, or benefits, and be sure to research the company culture and values to ensure they align with your own.