Clinical Review Nurse II

• Review and make complex medical determinations about whether claims meet the member's benefits
• Assess the necessity and reasonableness of items supplied in valid claims using medical policy
• Comprehend medical policy and criteria and clearly articulate health information
• Support federal programs through claims administration, data, and care delivery solutions
• Follow Government Business Division policies, procedures, guidelines, training, monitoring, and sensitive data handling requirements where applicable

Requirements

• Associate degree in nursing and minimum of 3 years of clinical experience, or an equivalent combination of education and experience
• Current unrestricted RN license required
• Applicants for the Wellpoint Federal division must have lived in the United States for at least three of the past five years if foreign nationals
• Ability to comprehend medical policy and criteria and clearly articulate health information strongly preferred
• Medical management or Utilization Review experience preferred
• Availability Monday through Friday, 8 am-5 pm EST based on the applicant's time zone, with some flexibility
• Candidates must reside within a reasonable commuting distance of a posting location unless an accommodation is granted
• Candidates may be subject to stringent and frequent background checks and/or government clearances, role-specific training, monitoring, segregation-of-duties principles, and sensitive data handling requirements for Government Business Division positions
• New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza unless an acceptable explanation is provided

Core Competencies

Demonstrates expertise in medical policy comprehension and claims assessment, with a strong focus on articulating health information and adhering to government regulations. Holds a current RN license and possesses clinical experience, particularly in medical management and utilization review.

Highest-signal resume keywords

• RN License
• Clinical Experience
• Medical Management
• Utilization Review
• Medical Policy Comprehension

ATS Optimization Keywords

Certifications & Qualifications

• Associate Degree in Nursing

Industry Keywords

• Claims Administration
• Health Information
• Government Business Division
• Data Handling Requirements
• COVID-19 Vaccination
• Influenza Vaccination