Team Lead, Clinical Care Review
About The Position
The Team Lead, Clinical Care Review is responsible for providing direct oversight of Clinical Care Review (CCR) employees and overseeing day-to-day workflow within the CCR team. This role ensures direct reports meet quality and productivity standards, understands health condition complexities, and manages workload effectively. The Team Lead acts as an advocate for the CCR team, providing feedback, guidance, and training. They are responsible for standardizing reporting, utilization review, and discharge planning for CareSource members, ensuring cost-effective delivery of healthcare services. This position assists management in process improvement, acts as a liaison between departments for problem resolution, and performs audits to ensure compliance with policies and regulatory guidelines. The Team Lead also contributes to team evaluations and goal development, presents UM informational meetings, and attends state hearings as necessary.
Requirements
- Graduate level degree as a mental health professional or Bachelor of Science degree in Nursing or equivalent years of relevant work experience is required
- One year of Utilization Management/Utilization Review experience required
- Basic computer skills
- Basic proficiency in Microsoft Word and Excel
- Communication skills
- Management skills
- Prior supervisory skills
- Ability to work independently and within a team environment
- Attention to detail
- Familiarity of the healthcare field
- Critical listening and thinking skills
- Training/teaching skills
- Negotiation skills/experience
- Proper grammar usage
- Time management skills
- Proper phone etiquette
- Customer service oriented
- Decision making/problem solving skills
- Leadership experience and skills
- Current, unrestricted license as a Registered Nurse (RN) or a mental health professional (i.e. Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), etc.) is required.
Nice To Haves
- Minimum of five (5) years clinical experience preferred
- Certified Care Manager experience is preferred
- Compact RN license or Multi-state Counselor/Social Worker licensure is preferred
- MCG Certification preferred
Responsibilities
- Provide direct oversight of CCR employees and oversee day-to-day workflow within the CCR team
- Ensure all direct reports are performing at minimum quality and productivity standards or better
- Understand complexities of health conditions and services
- Develop plan for management of workload after analyzing trends and act as advocate for CCR team
- Provide feedback, guidance, orientation, training and ongoing resources to CCRs and pre-authorization team
- Standardize activity and outcome reporting for department initiatives and programs including documentation required by the State and accrediting bodies
- Responsible for utilization review and discharge planning activities for CareSource members
- Monitor and ensure appropriate delivery of healthcare services in cost-effective manner
- Assist manager and director in development of process improvement activities and refining of processes that facilitate cost-effective utilization and appropriate levels of care
- Act as a liaison between Care Management, Claims, Enrollment, Customer Service and other areas as needed to assist in problem resolutions
- Perform audits of CCR team members to ensure compliance with CareSource policies, processes, regulatory requirements, NCQA utilization review guidelines and standards, and URAC review guidelines
- Provide input into CCR team evaluations and assist with development of team goals
- Design and present UM informational meetings as needed
- Responsible for attending state hearings as necessary
- Perform any other job duties as requested
Benefits
- In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
- We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
