Nurse Team Lead - Clin Rev

WNS Global Services•Houston, TX

1d•$74,880 - $85,280•Remote

About The Position

The Clinical Review Team Lead is the clinical subject matter expert for prospective utilization review. This is a working lead role that balances production case review with team leadership duties according to business needs and staffing, and provides secondary coverage for the Supervisor. The Team Lead resolves complex criteria and guideline questions, audits and coaches nurse reviewers, manages daily case inventory and turnaround times, and performs reviews as assigned. The role supports assigned benefit management programs and ensures compliance with applicable regulatory, accreditation, and client service requirements. It also works with Nursing Management, Clinical Review Training, Quality, Human Resources, physicians, other departments, and client personnel to support clinical review operations and resolve concerns.

Requirements

Graduate of an accredited school of nursing.
Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
At least three years of prospective utilization management experience making medical necessity determinations, such as prior authorization, pre-service review, or precertification, at a health plan, utilization management organization, or specialty or radiology benefit manager.
Experience auditing or reviewing other reviewers’ case work, precepting or training new staff, or serving as a go-to clinical resource for a team.
Sustained performance at or above productivity and quality (QA audit) standards in the current or most recent review role.
Expert application of evidence-based criteria (e.g., InterQual, MCG, or proprietary guidelines) across more than one program or modality, with the ability to explain clinical rationale to nurses and providers.
Working knowledge of utilization management regulatory and accreditation requirements, including URAC, NCQA, CMS and state turnaround times, Medicare NCDs/LCDs, and denial notice requirements.
Strong analytical skills, including use of Excel sorting, filtering, formulas, and pivot tables, and operational reports to monitor productivity, queues, and turnaround times and identify trends.
Highly organized, with the ability to manage inventory and multiple priorities in a fast-paced, changing environment.
Clear, professional written and verbal communication skills, including the ability to give constructive feedback.
Proficiency in Microsoft Office (Outlook, Excel, Word, and PowerPoint); Visio is a plus.
Ability to work from a HIPAA-compliant remote location with reliable high-speed internet.
Ability to use the telephone, sit, enter data, and view a PC screen for up to eight hours.
Ability to prioritize in a multi-task environment.

Nice To Haves

Review experience in two or more specialty program areas, such as Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, Radiation Therapy, or Genetic Testing.
Formal team lead, QA auditor, trainer, or preceptor role within a utilization management department.
Experience with workforce or inventory tools such as a case assignment tool, AVAYA, or ADP Workforce Now.
Knowledge of adverse determination and denial letter language requirements.
UM or quality certification, such as CPUM, CPUR, CCM, or CPHQ.
Multistate (compact) nursing license.
Visio proficiency.

Responsibilities

Serve as the clinical subject matter expert for assigned programs and modalities, answering nurses’ questions about criteria, guidelines, and processes, including through the clinical education mailbox.
Perform prospective case reviews as assigned while meeting established Team Lead productivity and quality standards during production hours.
Handle complex, escalated, and expedited cases, as well as escalated inbound provider calls and requests.
Interpret HealthHelp clinical guidelines, client medical policies, and regulatory requirements for the team; identify guideline gaps or inconsistencies for Nursing Management.
Coordinate daily physician reviewer case flow and notifications.
Monitor case inventory, queues, and turnaround times throughout the day; adjust nurse assignments based on staffing, proficiency, request type, and volume to meet client and regulatory service levels.
Use productivity, turnaround-time, and queue reports to identify backlogs, outliers, and trends, and recommend staffing or workflow changes to the Supervisor.
Use AVAYA, ADP Workforce Now, and related systems to manage daily phone and staffing metrics.
Audit nurse case work for determination appropriateness, documentation, and denial-related language; identify individual and team training needs.
Support new nurses through orientation and ramp-up, including QA audits and feedback, in coordination with Nursing Management and the Clinical Review Training Department.
Conduct regular one-on-ones with Clinical Review Nurses concerning review quality, productivity, and process.
Recommend improvements to clinical review processes, criteria application, tools, and job aids.
Provide secondary Nursing Management coverage when the Supervisor or Manager is unavailable.
Communicate assignments, expectations, and changes clearly and professionally; serve as a liaison between frontline staff and management.
Listen to team feedback, resolve or escalate day-to-day issues, and foster a respectful, motivating team environment.
Lead or participate in team meetings as directed.
Collaborate with other departments and client personnel to resolve concerns and obtain clarifications.
Know the requirements of assigned benefit management programs, including regulatory compliance, accreditation standards, and client service levels by line of business and geographic region.
Refer complaints to the Compliance Officer as appropriate and work with the Quality Department to investigate and correct errors.
Evaluate and report HIPAA breaches according to policy.
Collaborate with Human Resources to ensure adherence to company policies.
Adhere to HIPAA, state and federal regulations, and applicable URAC and NCQA standards.
Perform other related duties and projects as assigned.