Utilization Management Nurse Team Lead

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.

• Serve 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
• Perform 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

• 3 years Clinical experience preferred
• 2 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)

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.

• 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

Health One 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.