Lead Utilization Review - RN
About The Position
Every delayed or unclear coverage decision is a person waiting on care they need. The RN UM Team Lead makes sure that doesn't happen — coaching reviewers to apply medical-necessity criteria consistently, catching risk before it becomes a backlog, and keeping documentation audit-ready so decisions hold up under scrutiny. This isn't a background role: it's the difference between a member getting a timely answer and getting stuck in a queue. You're the person providers and internal teams turn to when a case gets complicated and needs a clear path forward. When your team runs tight, members get faster answers, providers get fewer headaches, and the business stays compliant — that's the job. Schedule: Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required. What You'll Actually Do Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception. Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary. Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem. Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness. Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems. Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving. Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team. Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same.
Requirements
- Active RN license
- Experience in utilization management, clinical review, or case management
- Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting
- Proficiency with UM platforms and standard office/productivity tools
- Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation
- Familiarity with remote collaboration tools for team visibility and responsiveness
Responsibilities
- Set daily direction for your UM team: Establish priorities, reinforce expectations, and build a culture where clinical quality and accountability are the norm, not the exception.
- Coach reviewers on criteria application: Guide consistent use of medical-necessity criteria, medical policy, and benefit language, and step in with real-time answers when interpretations vary.
- Monitor workflow health daily: Track intake volume, aging cases, and turnaround risk; flag barriers to the UM Manager with a recommendation attached, not just a problem.
- Audit for documentation quality: Review reviewer work for completeness and audit readiness, then coach for sharper clinical rationale and tighter regulatory timeliness.
- Build reviewer capability: Run shadowing plans, job aids, and competency check-ins for new and existing staff; identify training gaps and propose solutions before they become bigger problems.
- Resolve cross-team barriers: Partner with providers, facilities, Case Management, Appeals, and Provider Relations to clear roadblocks and keep determinations moving.
- Protect member and company data: Maintain HIPAA compliance and company privacy standards, and model the ethical decision-making you expect from your team.
- Drive training completion: Complete required training and attestations on time, and keep your team on track to do the same.
Benefits
- Competitive base salary and benefits effective day one
- Comprehensive medical and dental through our own health solutions (yes, we use what we build)
- Paid Time Off—rest and recharge time is non-negotiable
- Mental health support, retirement planning, and financial protection
- Professional development with clear career progression and learning budgets
- Mission-driven culture where diverse perspectives drive real impact on people's health
- Complete benefits package, wellness programs, and other employee perks.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
