Nurse Reviewer

Elevance Health

Nurse Reviewer 1 responsible for conducting preauthorization reviews for diagnostic imaging services. Collaborating with healthcare providers to ensure quality member outcomes and optimize benefits.

Posted 7/14/2026full-timeGrand Prairie • Florida, Ohio, Texas • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in conducting medical necessity clinical screenings and preauthorization reviews for diagnostic imaging services, ensuring compliance with Utilization Management Guidelines and optimizing member benefits. Strong collaboration with healthcare providers to promote high-quality outcomes is essential.

Highest-signal resume keywords

RN LicenseClinical Nursing ExperienceUtilization Management GuidelinesICD-10 CodingCPT-4 Coding

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity Clinical ScreeningsPreauthorization ReviewsDiagnostic Imaging ServicesOut Of Network ServicesQuality Management

Soft Skills

CollaborationCommunication

Certifications & Qualifications

Current Unrestricted RN License

Industry Keywords

Utilization ManagementManaged Health CareHMOPOPOS Plans

About the role

Key responsibilities & impact

conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines
collaborating with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits
working on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management
partnering with more senior colleagues to complete non-routine reviews
conducting medical necessity clinical screenings of preauthorization requests to assess the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment

Requirements

What you’ll need

Requires AS in nursing and minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting or minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background
Current unrestricted RN license in applicable state(s) required
BA/BS degree preferred
Familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred
Previous utilization and/or quality management and/or call center experience preferred

Benefits

Comp & perks

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