Clinical Review Nurse Lead

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🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟠 Senior

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Elevance Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Elevance Health is transforming from a traditional health benefits organization into a lifetime trusted health partner, driven by a bold purpose to improve the health of humanity. With nearly 100,000 associates, they serve over 118 million people and utilize an integrated whole health approach supported by industry-leading capabilities and a digital health platform. Their mission includes redefining health, reimagining the health system, and strengthening communities.

📋 Description

• Serve as team lead for nursing staff collaborating with healthcare providers and members • Promote quality member outcomes, optimize member benefits, and support effective resource use for complex or elevated medical issues • Assess medical necessity of home health and outpatient services and appropriateness of treatment settings • Apply medical policy, industry standards, benefits, and managed care products to ensure medically appropriate, high-quality, cost-effective care • Work with medical directors to interpret appropriateness of care and ensure accurate claims payment • Manage appeals for denied services as needed • Conduct pre-certification and treatment-setting appropriateness reviews • Consult with clinical reviewers and medical directors throughout the medical management process • Respond to the most complex medical issues and ensure consistency in benefit application • Lead cross-functional teams, projects, initiatives, and process improvement activities as needed • Serve as departmental liaison or representative on enterprise initiatives

🎯 Requirements

• Associate degree in nursing and minimum of 7 years of acute care clinical experience, or an equivalent combination of education and experience • Prior managed care experience required • Current unrestricted RN license in applicable state(s) required • For Wellpoint Federal: foreign national applicants must have lived in the United States at least three of the past five years • May be subject to stringent and frequent background checks and/or government clearances • Must follow Government Business Division policies, procedures, guidelines, training, monitoring, and sensitive data handling instructions when applicable • Leadership experience overseeing clinical review operations, guiding staff, driving quality initiatives, and ensuring compliance with CMS requirements preferred • BS in nursing preferred • Strong clinical background preferred • Home health nursing experience preferred • Prior authorization nursing experience preferred • Medicare experience preferred • Experience training and presenting preferred • COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided

🏖️ Benefits

• Virtual full-time work arrangement with flexibility and autonomy • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical benefits • Dental benefits • Vision benefits • Short-term disability benefits • Long-term disability benefits • 401(k) with match • Stock purchase plan • Life insurance • Wellness programs • Financial education resources • COVID-19 and Influenza vaccination support/requirement for certain patient/member-facing roles