Nurse Team Lead - Clin Rev

HealthHelp•Houston, TX

2d•$74,880 - $85,280•Hybrid

About The Position

WNS, part of Capgemini, is an Agentic AI-powered leader in intelligent operations and transformation, serving more than 700 clients across 10 industries. This role involves balancing case review production with team lead duties, conducting case reviews, monitoring staff performance, and acting as a liaison between frontline staff and upper management. The position also requires assisting with physician reviewer case coordination, disseminating information, evaluating case work, providing support to staff, and collaborating with other departments. Additionally, the role involves conducting selected reviews/auditing of cases to identify training opportunities, coordinating with Nursing Management and the Clinical Review Training Department, conducting one-on-ones with nurses, identifying process improvements, and participating in educational group emails. Standard departmental responsibilities include providing secondary Nursing Management coverage, handling escalated calls, assisting with inventory management, participating in meetings, developing and utilizing a rewards system, using empowerment and trust to motivate team members, facilitating a healthy work environment, managing daily phone metrics, collaborating with client personnel, understanding benefit management programs, referring complaints to Compliance, evaluating HIPAA breaches, collaborating with HR, promoting business focus, and fostering teamwork, respect, diversity, and cooperation. Adherence to HIPAA, state and federal regulations, URAC, and NCQA standards is required.

Requirements

Graduate of an accredited school of nursing
Current active, unrestricted RN or LVN/LPN license in a state or territory of the United States required
Minimum of 2 years of Utilization Management (UM) experience required
Minimum of 1 year of Supervisory Experience.
Excellent interpersonal, written and presentation skills, including the ability to handle interactions with facility personnel, providers, members and various internal departments in a professional manner
Demonstrates leadership and motivational skills
Ability to work in a fast-paced, evolving environment
Ability to utilize critical thinking skills
Experience in team interactions and improvement methods/projects (e.g., coaching quality and productivity)
Understanding of HealthHelp’s products and services
Strong interpersonal and communication skills
Knowledge of Microsoft Office and programs including Outlook, PowerPoint, Excel, Word and Visio

Nice To Haves

additional experience in QM, acute care, or managed care setting preferred
on-call after hours work may be required

Responsibilities

Balances between case review production and team lead duties based on business needs and staffing levels
Conducts case reviews as assigned. Maintains a minimum target of 3.5 cases per hour (CPH) when processing cases during productivity hours
Monitors staff work assignments and adjusts the nurse assignment tool based on staffing levels, proficiency, types of request, and amount of cases received
Ensures case-specific turnaround time (TAT) related to client service level agreements and regulatory compliance requirements are met for their specified program(s)
Communicate expectations, assignments and responsibilities clearly and professionally
Acts as a liaison between frontline staff and upper management
Assists with daily physician reviewer case coordination and notifications
Monitor team performance to ensure proper processes are being followed and report on areas of opportunity to Supervisor
Functions as a subject matter expert for assigned program modalities/procedures
Disseminates information, as appropriate, to staff members
Evaluates and monitors case work by team members to identify any gaps or outliers
Ensures that staff members are successful by providing support to new and existing staff as a valuable resource
Listen to team members’ feedback and resolve any issues or conflicts
Enables team members to ensure consistent quality service to provider and members
Collaborates with other departments, as assigned, to ensure proper protocol is being followed and obtain clarifications, as needed
Conducts selected reviews/auditing of cases within the Clinical Review department to identify training opportunities based on appropriateness of the review determinations
Coordinates with Nursing Management and Clinical Review Training Department to identify educational and refresher training needs for individual nurses or across the Clinical Review Department
Conducts periodic one-on-ones with Clinical Review Nurses to offer tips on process improvement and clinical review
Identify potential improvements in clinical review process and criteria
Participate in HH Nurse Education group email to provide responses to nurses’ questions regarding specific cases and clinical review processes
Provide secondary Nursing Management coverage for assisting staff during Manager or Supervisor unavailability due to meetings, PTO, etc.
Handles escalated inbound calls or requests from providers
Assists with inventory management, including monitoring case volumes and queues to support timely assignment and completion
Actively participates or conducts meetings as directed by Supervisor or Manager
Develop, implement, and utilize a multifaceted rewards system that makes team members excited to show up to work every day and do their best
Use empowerment, trust and other strategies as appropriate to develop and motivate team members
Facilitate a healthy and motivating work environment and atmosphere
Utilizes knowledge of AVAYA, ADP Workforcenow. and related systems to manage daily phone metrics
Capable of collaborating with client personnel to resolve customers’ concerns
Responsible for knowing the intricacies of all benefit management programs including applicable regulatory compliance, accreditation standards, and client/health plan service level requirements for each program, line of business, and geographic region
Refers all complaints to Compliance Officer, as appropriate; works collaboratively with the Quality Department to investigate complaints and correct errors
Evaluate and report HIPAA breaches according to policy
Collaborates with human resources to ensure adherence to company policies
Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy
Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others
Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs
Adheres to both URAC & NCQA standards pertinent to their job description
Performs other related duties and projects as assigned