Clinical Review Nurse Lead

Elevance Health•Tampa, FL

1d•Remote

About The Position

The Clinical Review Nurse Lead is responsible for serving as a team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of home health services, outpatient services and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Requirements

Requires AS in nursing and minimum of 7 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
Prior managed care experience required.
Current unrestricted RN license in applicable state(s) 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.
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.

Nice To Haves

Leadership experience in overseeing clinical review operations, guiding staff on clinical review, driving quality initiatives, and ensuring compliance with CMS requirements.
BS in nursing.
Strong clinical background.
Home health nursing experience.
Prior authorization nursing experience.
Medicare experience.
Experience training and presenting.

Responsibilities

Conducts pre-certification and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Serves as the team lead and responds to the most complex medical issues. Ensures consistency in benefit application.
May lead cross-functional teams, projects, initiatives, and process improvement activities, and requires previous managed care experience.
May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.