Lead Clinical Review Nurse

Elevance Health • Mason, IN

16d • Remote

About The Position

Location: 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. The Lead Clinical Review Nurse is responsible for serving as a team lead for nursing staff who collaborate with cross functional teams and healthcare providers to promote quality audits, and to promote education, training for the DRGV team. Effective use of resources for the most complex or elevated issues. Ensures clinically high quality, cost effective care through assessing coding of inpatient admissions, focused surgical and diagnostic procedures by utilizing the applicable coding guidelines and industry standards, accurately interpreting coding clinics, and other approved coding advice. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals. How you'll make a difference: Conducts retrospective reviews, and appropriateness of coding to ensure compliance with applicable criteria and contracts. Ensures member access to quality healthcare in a cost effective setting according to contract. Consults with clinical reviewers and/or medical directors to ensure appropriate coding assignment. Collaborates with providers to verify correct DRG assignment aiding in identification of any coding errors. Facilitates transition of patient information for correct interpretation and regulatory requirements and standards. Serves as the team lead and responds to the most complex audit issues. Ensures consistency in audit application. May lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous auditing experience. May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

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

Nice To Haves

• BS in nursing preferred
• Knowledge of medical payment methodologies process and ability to interpret and apply provider contracts, strongly preferred
• Claims Auditing experience is strongly preferred
• CCS, RHIT, RHIA coding certificate

Responsibilities

• Serves as a team lead for nursing staff
• Collaborates with cross functional teams and healthcare providers to promote quality audits
• Promotes education, training for the DRGV team
• Effective use of resources for the most complex or elevated issues
• Ensures clinically high quality, cost effective care through assessing coding of inpatient admissions, focused surgical and diagnostic procedures by utilizing the applicable coding guidelines and industry standards, accurately interpreting coding clinics, and other approved coding advice
• Works with medical directors in interpreting appropriateness of care and accurate claims payment
• May also manage appeals
• Conducts retrospective reviews, and appropriateness of coding to ensure compliance with applicable criteria and contracts
• Ensures member access to quality healthcare in a cost effective setting according to contract
• Consults with clinical reviewers and/or medical directors to ensure appropriate coding assignment
• Collaborates with providers to verify correct DRG assignment aiding in identification of any coding errors
• Facilitates transition of patient information for correct interpretation and regulatory requirements and standards
• Serves as the team lead and responds to the most complex audit issues
• Ensures consistency in audit application
• May lead cross-functional teams, projects, initiatives, process improvement activities, and requires previous auditing experience
• May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree