Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials. The clinical nurse reviewer will be responsible for reviewing and adjudicating claims. Minimum Requirements:Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license required. This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years. Preferred Skills, Capabilities, and Experiences:BS in nursing preferred. Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred. Home Health or Hospice is preferred. Knowledge of Medicare guidelines preferred. If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed. Job Level:Non-Management Exempt. Workshift:1st Shift (United States of America)