Case Reviewer (NP/PA) - Ortho Surgery - NY Staffing : Job Details

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Case Reviewer is responsible for conducting pre-authorization, out of network and appropriateness of tests by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of required tests, medications, interventional procedures and surgeries to ensure quality member outcomes, and to optimize member benefits.

How you will make an impact:

• Receives pre-authorization requests from front-line intake and nurse reviewers.
• Conducts initial medical necessity clinical screenings.
• Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director.
• Works closely with Medical Directors to review and make recommendations regarding medical necessity of requested tests, medications, interventional procedures and surgeries.
• Documents the results of the initial clinical review and determination in the pre-certification system.
• Conducts initial medical necessity review of out of network pre-authorization requests for services.
• Conducts review of grievance and appeals requests to provide to Medical Directors.

Minimum Requirements:

• Requires MA/MS from an ARC-PA (Accreditation Review Commission for the Physician Assistant) accredited program or an ACEN/CCNE (Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education) accredited program.
• Minimum of 3 years of clinical experience is also required.
• Certified and current, active, unrestricted license as a Physician Assistant or APRN (Advanced Practice Registered Nurse) in applicable state(s) required.
• AAPA (American Academy of PAs) and applicable state license required for Physician Assistants.
• APRN and applicable state license(s) required for Nurse Practitioners.

Preferred Skills, Capabilities, and Experiences:

• Experience in orthopedic outpatient/inpatient settings, and orthopedic OR strongly preferred.

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.