This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Professional Review Analyst analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided. This is a remote role. Candidate must be located in the greater Charlotte, North Carolina Region and able to attend in office training for a minimum of 1 week at start of employment. Essential Functions & Responsibilities: - Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager. - Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans. - Appropriately document work and final conclusions in designated computer program. - Additional duties as assigned. Qualifications - Thorough knowledge of ICD Diagnoses and Procedure Codes, and C.P.T., as well as an understanding of medical terminology. - Knowledge of applicable fee schedule and or applicable U&C Guidelines. - Proficient in Microsoft Office applications. - Technical aptitude with the ability to expand knowledge of MedCheck’s proprietary systems. - Ability to work independently, follow process guidelines, and meet productivity standards and timelines (must maintain a score of 98% or higher on performance audits). Requirements - Associate’s degree or equivalent experience. - CPC or CPC-A required. - Previous experience in the following areas preferred: - Medical bill auditing. - Knowledge of workers' compensation claims process. - Prospective, concurrent and retrospective utilization review. Benefits - CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. - Pay Range: $19.24 - $31.04 per hour. - A comprehensive benefits package is available for full-time regular employees and includes: - Medical (HDHP) w/Pharmacy. - Dental. - Vision. - Long Term Disability. - Health Savings Account. - Flexible Spending Account Options. - Life Insurance. - Accident Insurance. - Critical Illness Insurance. - Pre-paid Legal Insurance. - Parking and Transit FSA accounts. - 401K, ROTH 401K. - Paid time off.

Anticipated End Date: 2026-03-16 Position Title: Nurse Reviewer I Job Description: Virtual: 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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. Work schedule: Monday - Friday 9:30am – 6pm local time, with rotating weekends. (Saturday 8am-12pm CST, with a comp day during the week) The Nurse Reviewer I will be responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. - Collaborates 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. - Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. - Partners with more senior colleagues to complete non-routine reviews. - Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. How you will make an impact: - 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​: - Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PPO and POS plans strongly preferred. - BA/BS degree preferred. - Previous utilization and/or quality management and/or call center experience preferred. - RN Compact License is strongly preferred; CA RN License is also preferred. - Experience in cardiology/radiology is preferred but not required. For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $36.27 to $56.77 Locations: California. 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. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are 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. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. 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 will also follow all relevant federal, state and local laws. 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. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

Thank you for considering a career at Ensemble! Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: - Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. - Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. - Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. The Opportunity: CAREER OPPORTUNITY OFFERING: - Bonus Incentives - Paid Certifications - Tuition Reimbursement - Comprehensive Benefits - Career Advancement This position pays: - RN pay scale $32.65 - $35.85/hr based on experience - LPN pay scale $24.65 - $26.35/hr based on experience **Must have Current unrestricted LPN or RN license (required) or RN compact license (preferred)** We are seeking Virtual Utilization Review Specialists to join our team. The schedules we are offering include: Weekday work schedule: - Full-time: Monday - Friday: 8:30 am - 5:00 pm, rotating weekends and holidays Essential job function include: Resource Utilization - Utilizes proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/under utilization of services - Initiates appropriate referral to physician advisor in a timely manner - Understands proper utilization of health care resources and assists with identifying barriers to patient progress and collaborates with the interdisciplinary team - Collaborates with financial clearance center, patient access, financial counselors and/or business office regarding billing issues related to third party payers Medical Necessity Determination - Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria to determine medical necessity for admissions including appropriate patient status and continued stay reviews, possibly from an offsite location - Provides inpatient and observation (if indicated) clinical reviews for commercial carriers to the Financial Clearance Center (FCC) within one business day of admission - Communicates all medical necessity review outcomes to in-house care management staff and relevant parties as needed - Collaborates with the in-house staff and/or physician to clarify information, obtain needed documentation, present opportunities and educate regarding appropriate level of care - Collaborates with the financial clearance center, patient access, financial counselors, and/or business office regarding billing issues related to third party payers Denial Management - Coordinates the P2P process with the physician or physician advisor, FCC, Revenue Cycle team when necessary and when assigned and maintains documentation relevant to the appeal process. - Maintains appropriate information on file to minimize denial rate - Assist in recording denial updates; overturned days and monitor and report denial trends that are noted - Monitor for readmissions Quality/Revenue Integrity - Demonstrates active collaboration with other members of the health care team to achieve the outcomes management goals including CMS indicators - Accurately records data for statistical entry and submits information within required time frame - Responsible for ConnectCare and ADT work queues assigned to VUR for revenue cycle workflow - Accurately records data for statistical entry and submits information within required time frame - Documentation will reflect all work and communication related to the FCC, payor, physician, physician advisor and in-house care management - Second-level physician reviews will be sent as required and responses/actions reflected in documentation Facilitation of Patient Care - Prioritizes patient reviews based on situational analysis, functional assessment, medical record review, and application of clinical review criteria - Collaborates with the in-house care manager Maintains rapport and communication with the in-house care manager Demonstrates the knowledge and skills necessary to provide care appropriate to the age of the patients served on his or her assignment - Demonstrates knowledge of the principles of growth and development of the life span and possesses the ability to assess data reflective of the patient's status and interprets the appropriate information needed to identify each patient's requirements relative to his or her age, specific needs and to provide the care needed as described in departmental policies and procedures Communication - Directs physician and patient communication regarding non-coverage of benefits - Maintains positive, open communication with the physicians, nurses, multidisciplinary team members and administration - Educates hospital and medical staff regarding utilization review program. - Maintains a calm, rational, professional demeanor when dealing with others, even in situations involving conflict or crisis - Voicemail, Skype, and email will be utilized and answered in timely fashion. Hospital provided communication devices will be used during work hours. - Staff is expected to respond and/or acknowledge communication from the FCC via approved communication guidelines and standardized service-line agreements - Staff must be available as designated for meetings or training, onsite or online, unless prior arrangements are made Team Affirmation - Works collaboratively with peers to achieve departmental goals in daily work as evidenced by appropriate and timely communication which is respectful and clear. Sensitive to workload of peers and shares responsibilities, fills in and offers to help - Actively participates in departmental process improvement team; planning, implementation, and evaluation of activities - Provides back-up support to other departmental staff as needed Other Job Functions - Complies with FCC and department policies and procedure, including confidentiality and patient’s rights. - Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities (i.e., medical necessity criteria, MS-DRGs, POA). - Actively participates in departmental meetings and activities. - Participates in FCC and community committees as assigned. - Actively participates in conferences, committees, and task forces as directed by the FCC division. - Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation. Experience: - Bachelor's Degree or equivalent experience; Specialty/Major: Nursing or related field - Current unrestricted LPN or RN license required; RN compact license preferred - Three years nursing experience in an acute care environment preferred - Utilization review/discharge planning experience preferred - Recent experience or working knowledge of medical necessity review criteria preferred - Current working knowledge of quality improvement processes Other Knowledge, Skills, and Abilities Required: - This is a remote role which requires access to high speed internet - Excellent interpersonal, communication and negotiation skills in interactions with physicians, payors, and health care team colleagues - Commitment to exceptional customer service at all times - Communicate ideas and thoughts effectively verbally and in writing - Strong clinical assessment, organization and problem-solving skills - Ability to assess and identify appropriate resources, internal and community, on assigned caseload, and to work collaboratively with health care team, providers, and payors to achieve the desired patient, quality, and financial outcomes - Ability to prioritize, organize information, and complete multiple tasks effectively in a fast-paced environment - Resourceful and able to work independently #LI-LS1 #LI-Remote Join an award-winning company Five-time winner of “Best in KLAS” 2020-2022, 2024-2025 Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024 Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024 Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023 Energage Top Workplaces USA 2022-2024 Fortune Media Best Workplaces in Healthcare 2024 Monster Top Workplace for Remote Work 2024 Great Place to Work certified 2023-2024 - Innovation - Work-Life Flexibility - Leadership - Purpose + Values Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include: - Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs. - Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation. - Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. - Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company. Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories. Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com. This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range. EEOC – Know Your Rights FMLA Rights - English La FMLA Español E-Verify Participating Employer (English and Spanish) Know your Rights

Anticipated End Date: 2026-03-21 Position Title: Nurse Audit Lead Job Description: Nurse Audit Lead Location: Virtual: This role enables associates to work virtually full-time, except for 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 Nurse Audit Lead is responsible for leading a team of clinicians responsible for identifying, monitoring, and analyzing aberrant patterns of utilization and/or fraudulent activities by health care providers through prepayment claims review, post payment auditing, and provider record review. How you will make an impact: - Develops, maintains and enhances the claims review process. - Assists management with developing unit goals, policies and procedures. - Investigates potential fraud and over-utilization by performing the most complex medical reviews via prepayment claims review and post payment auditing. - Correlates review findings with appropriate actions (provider education, recovery of monies, cost avoidance, recommending sanctions or other actions. - Acts as principal liaison with Service Operations as well as other areas of the corporation relative to claims reviews and their status. - Notifies areas of identified problems or providers, recommending modifications to medical policy, on line policy edits. - Communicates and negotiates with providers selected for prepayment review. - Assists investigators by providing medical review expertise to accomplish the detection of fraudulent activities. - Trains and provides guidance to nurse auditors and manages workflow and priorities for the unit. Minimum Qualifications: Requires AS in nursing and minimum of 5 years of clinical experience and minimum of 2 years of claims review 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: - BA/BS preferred. - Knowledge of auditing, accounting and control principals and working knowledge of CPT/HCPCS and ICD 9 coding and medical policy guidelines strongly preferred. - Prior health care fraud audit/investigation experience preferred. - Certification as a Professional Coder preferred. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are 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. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. 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 will also follow all relevant federal, state and local laws. 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. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.