Clinical Waste & Abuse Nurse Lead

Job description

Clinical Waste & Abuse Nurse Lead - Evernorth As a Clinical Waste & Abuse Nurse Lead, you bring clinical expertise and thoughtful judgment to help protect patients, strengthen payment integrity, and support high-quality care. You play a critical role in identifying waste and abuse trends while coaching others and shaping smarter, more effective review practices. We are an ambitious, compassionate team committed to doing what’s right—for members, providers, and one another. Responsibilities: Lead complex clinical reviews that assess medical necessity, coding accuracy, and billing integrity to drive appropriate claim outcomes Identify patterns, trends, and opportunities that strengthen cost containment and payment integrity initiatives Serve as a trusted escalation partner for complex or non-routine cases, guiding resolution through sound clinical judgment Coach, train, and mentor peers and new hires, helping build confidence, consistency, and clinical excellence Partner with Medical Directors and cross-functional teams to advance high-quality, clinically sound decisions Contribute to the development of tools, job aids, workflows, and documentation that improve efficiency and clarity...