Utilization Review Clinical Team Lead

PRIMARY PURPOSE: To provide services for dedicated accounts; to ensure the efficient, cost effective, and high quality delivery of utilization review service by supervising 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.

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Trains and develops utilization review staff.
• Supervises a team of nurses ensuring utilization management services are delivered promptly, cost effectively, courteously, and according to legal requirements, operational, and quality assurance standards.
• Takes corrective action when necessary ensuring objectives, standards, policies and procedures are met.
• Works with program manager to establish and ensure achievement of office/unit customer service, utilization patterns, productivity, quality and financial goals.
• Ensures that staff adheres to quality assurance and productivity standards: assists program manager in evaluating customer service utilization patterns, productivity, quality and financial results ensuring that service delivery is within parameters defined by the company.
• Performs active customer service function for account; provides day-to-day contact with customer to resolve service delivery problems/issues; responds to customer requests; communicates any special customer instruction or procedure that must be adhered to by the registered nurse.
• Advises staff of any pertinent changes in customer service delivery, regulatory mandates or business functions; provides training on regulatory issues.
• Makes recommendation for ongoing and future service delivery options; identifies referrals for case management.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization’s quality program(s).

SUPERVISORY RESPONSIBILITIES

• Administers company personnel policies in all areas and follows company staffing standards and training recommendations.
• Interviews, hires and establishes colleague performance development plans; conducts colleague performance reviews.
• Provides support, guidance, leadership and motivation to promote maximum performance.

QUALIFICATIONS

Education & Licensing
Active unrestricted RN license in a state or territory of the United States required. Bachelor’s degree from an accredited college or university preferred. CPUR or other related designation preferred.

Experience
Six (6) years of clinical practice experience or equivalent combination of education and experience required to include two (2) years of supervisory experience.

Skills & Knowledge

• Strong knowledge of utilization review practices
• Expert knowledge of the insurance industry and claims processing
• Acquired knowledge of GM claims process, plan design and customer needs
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Leadership/management/motivational skills
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT
When applicable and appropriate, consideration will be given to reasonable accommodations.

TAKING CARE OF YOU BY

•  We offer a diverse and comprehensive benefits package including:
  • Three Medical, and two dental plans to choose from.
  • Tuition reimbursement eligible.
  • 401K plan that matches 50% on every $ you put in up to the first 6% you save.
  • 4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.