Clinical Review Nurse Lead

This is a fully remote position, open to applicants in Florida.

📋 Description

• Act as the team leader for nursing personnel, collaborating with healthcare providers and members.

• Enhance quality outcomes for members, maximize member benefits, and facilitate effective resource utilization for complex or elevated medical situations.

• Evaluate the medical necessity of home health and outpatient services along with the suitability of treatment environments.

• Implement medical policies, industry standards, benefits, and managed care products to guarantee medically suitable, high-quality, cost-efficient care.

• Collaborate with medical directors to assess the appropriateness of care and ensure accurate claims processing.

• Manage appeals for denied services as necessary.

• Perform pre-certification and reviews for treatment-setting appropriateness.

• Consult with clinical reviewers and medical directors throughout the medical management process.

• Address the most complex medical challenges and ensure consistency in the application of benefits.

• Lead cross-functional teams, projects, initiatives, and process improvement activities as required.

• Represent the department as a liaison on enterprise initiatives.

⛳️ Requirements

• Associate degree in nursing with a minimum of 7 years of acute care clinical experience, or a comparable combination of education and experience.

• Previous managed care experience is mandatory.

• Current unrestricted RN license in relevant state(s) is required.

• For Wellpoint Federal: foreign national applicants must have resided in the United States for at least three of the last five years.

• May be subject to rigorous and frequent background checks and/or government clearances.

• Must adhere to Government Business Division policies, procedures, guidelines, training, monitoring, and sensitive data handling protocols when applicable.

• Preferred leadership experience in overseeing clinical review operations, guiding staff, driving quality initiatives, and ensuring CMS compliance.

• A Bachelor's degree in nursing is preferred.

• A strong clinical background is preferred.

• Experience in home health nursing is preferred.

• Prior authorization nursing experience is preferred.

• Experience with Medicare is preferred.

• Experience in training and presenting is preferred.

• COVID-19 and Influenza vaccinations are required for specific patient/member-facing roles unless an acceptable exemption is provided.

🏝️ Benefits

• Virtual full-time work arrangement offering flexibility and autonomy.

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) plan with matching contributions.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Support/requirement for COVID-19 and Influenza vaccinations for certain patient/member-facing roles.