Clinical Review Nurse Lead

About the role

The offer for this position is contingent upon Wellpoint Federal receiving final approval from the federal government to fund and commence this work. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.

Responsibilities

• Serve 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.
• Ensure 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.
• Work 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.

Qualifications

• 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.

Skills

Not specified.

Benefits

Not specified.

Pay

Not specified.

Schedule

Not specified.

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.

Additional Information

• Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health.
• Unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
• 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.