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A proud member of the Elevance Health family of companies, Carelon Global Solutions, formerly Legato Health Technologies is a managed service delivery organization, providing information technology and business operations services for health plans.

Nurse Reviewer I

Location: This position will work on-site on Carelon PR building located on 654 Ave Munoz Rivera San Juan, Puerto Rico.

Schedule: This position will work a first shift but must be flexible to the US States time zones that the unit will be supporting.

The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines.

How you will make an impact

Primary duties may include, but are not limited to:

• Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

• Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.

• Notifies ordering physician or rendering service provider office of the preauthorization determination decision.

• Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Minimum Requirements:

• 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.

Preferred Skills, Capabilities, and Experiences:

• NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States.

• Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.

• BA/BS degree preferred.

• Previous utilization and/or quality management and/or call center experience preferred.

• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.