Lead Clinical Review Nurse

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.

• 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.

• 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.

• 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.

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 elevancehealthj 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.