Lead Clinical Review Nurse

Elevance Health Mason, OH, US

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Anticipated End Date:

2026-04-30

Position Title:

Lead Clinical Review Nurse

Job Description:

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.

Minimum 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.

Preferred skills, qualifications and experience:

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

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

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

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.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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.

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