Clinical Review Nurse I

Elevance Health

Clinical review nurse assessing medical necessity and benefits coverage for Wellpoint Federal claims. Supporting Elevance Health’s federal healthcare programs through policy-based determinations.

Posted 8/11/2026full-timeRemote • Kentucky, Pennsylvania, Texas • 🇺🇸 United StatesJunior💰 $67,200 - $110,880 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical policy comprehension and the ability to articulate health information clearly. Holds a current RN license and possesses clinical experience to assess claims and make medical determinations effectively.

Highest-signal resume keywords

Current Unrestricted RN LicenseClinical ExperienceMedical Policy ComprehensionClaims AssessmentSensitive Data Handling

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical DeterminationClaims ReviewHealth Information ArticulationClinical AssessmentPolicy Compliance

Soft Skills

Clear CommunicationAttention to Detail

Certifications & Qualifications

Associate Degree in Nursing

Industry Keywords

Government Business DivisionSensitive Data HandlingSegregation of DutiesCOVID-19 VaccinationInfluenza Vaccination

About the role

Key responsibilities & impact

Review and make medical determinations as to whether pre-claim reviews and/or claims meet the member’s benefits
Assess the necessity and reasonableness of items supplied in valid claims
Use medical policy and other materials to make determinations
Clearly articulate health information based on medical policy and criteria
Complete required in-person training and onboarding activities
Follow Government Business Division policies, procedures, guidelines, training, monitoring, and sensitive-data handling requirements when applicable

Requirements

What you’ll need

Associate degree in nursing required, or an equivalent combination of education and experience
Minimum of 1 year of clinical experience
Current unrestricted RN license required
Ability to comprehend medical policy and criteria and clearly articulate health information strongly preferred
Candidates must reside within reasonable commuting distance of a posting location unless an accommodation is granted
Candidates in sensitive Government Business Division positions may be subject to stringent and frequent background checks and/or government clearances
Candidates in sensitive Government Business Division positions must follow segregation-of-duties principles, role-specific training, monitoring of daily job functions, and sensitive-data handling instructions
Candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401(k) contribution
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 company match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Required in-person training sessions
Flexible and autonomous virtual work arrangement