Utilization Management Nurse Team Lead

MISSIONO

ur mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.

VALUES Health

One is guided by a cultural framework that embodies our values and drives our decisions.

Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.

Health One seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, Health One provides the means to help you achieve your goals.

JOB PURPOSE The UM Nurse Team Lead ensures efficient, cost effective, and high quality delivery of utilization review service by supporting and training a staff of registered nurses; to oversee the management of medical cases worked by registered nurses; to oversee individual and overall results/outcomes of all cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs.

ESSENTIAL JOB DUTIESServe as a clinical and operational team lead for Utilization Management nurses, providing day to day guidance, mentorship, and clinical support

Act as an escalation resource for complex utilization reviews, appeals, and provider/member issues requiring advanced clinical judgment

Trains and develops utilization review staff

Works with Utilization Management Manager to establish and ensure achievement of completion of prior authorization reviews, productivity, and quality goals

Initiate referrals to ensure appropriate coordination of care

Seek the advice of the Medical Director when appropriate, according to policy

Assists non-clinical staff in performance of administrative reviews

Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility

Maintains regular and predictable attendance

Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice

Works to encourage and promote Company culture throughout the organization

Other duties as may be assigned

QUALIFICATIONS3 years Clinical experience preferred2 years of Utilization Review Proficient in Microsoft Office (Outlook, Word, Excel)
Working knowledge of NCQA preferred

Must be able to work in an independent and creative manner

Ability to manage multiple projects and priorities

Adaptive to high pace and changing environment

Customer service oriented

Proficient in interpreting benefits, contract language and medical policy/medical review criteria

Current, active Compact State license in Nursing (RN)

PHYSICAL REQUIREMENTS Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.

BENEFITS
401K (4% Match, Immediate Vesting)
Accident insurance

Competitive salary

Critical Illness Insurance Dental Insurance Employee Assistance Program Flexible Spending Account Health & Wellness Program Health Savings Account Life & AD&D Insurance Long Term Disability Medical Insurance Paid Time Off Pet Insurance Short Term Disability Vision Insurance

PRE-EMPLOYMENT SCREENING Drug Screen and Background Check Required

HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law.
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