Team Leader - RN - Clinical Review

Blue Cross Blue Shield of Michigan•United States,

About The Position

Responsible for planning, coordinating, and supervising assigned departments or areas to ensure efficient and cost-effective operations in accordance with corporate and departmental policies and procedures. The role supports staff development, strategic improvements, and effective use of technology, personnel, and resources. The Team Leader oversees clinical review operations, supports non-nursing staff with clinical issues, reviews operational data related to assessment triggers, care-plan goals, and goal completion rates, and collaborates with Medical Consultants, Medical Directors, professional teams, and health care providers to develop treatment plans and goals as needed.

Requirements

Associate’s degree in nursing or RN Diploma required.
Three to six years of clinical experience.
Two years of supervisory experience.
Current unrestricted Registered Nurse license in the state of Michigan.
Strong organizational, planning, analytical, and communication skills.
Excellent interpersonal skills to interact with personnel at all levels.
Daily travel to an assigned on-site facility where applicable.
For nurses working on site where applicable, proof of auto liability coverage, a valid current Michigan driver’s license, and reliable personal transportation.
Other related skills or abilities may be required to perform the job.

Nice To Haves

Bachelor’s degree preferred.
At least three years of utilization management or utilization review experience in an acute care, health plan, or managed care setting preferred.
At least three years of experience working in Clinical Review Coordinators (CRC) or with medical policy reviews.
Proficiency in applying and interpreting medical policy and InterQual Criteria, including Post Acute Care subsets, to support medical necessity and level-of-care determinations preferred.
Strong knowledge of National Committee for Quality Assurance (NCQA) Utilization Management standards, accreditation requirements, and quality improvement processes preferred; awareness of Centers for Medicare & Medicaid Services (CMS) regulations is a plus.
Experience leading teams, facilitating collaborative problem-solving, and driving departmental performance outcomes preferred.
Experience in care coordination or leading care coordination teams, including collaboration with Care Management and Medical Directors, preferred.
Excellent critical thinking, clinical judgment, and decision-making skills related to utilization management preferred.
Strong written and verbal communication skills for interacting with physicians, interdisciplinary teams, leadership, and internal and external stakeholders preferred.
Experience monitoring quality metrics, regulatory compliance, and departmental performance indicators preferred.
Ability to build a culture of accountability, engagement, and continuous improvement preferred.
Demonstrated success in staff coaching, conflict resolution, and change management preferred.
Strong organizational skills and ability to prioritize competing demands while meeting regulatory and operational deadlines preferred.
Commitment to delivering high-quality, patient-centered, and compliant utilization management services preferred.
Working knowledge of PC applications and/or mainframe systems preferred.

Responsibilities

Supervise assigned staff and promote their professional development through selection, development, and exploration of effective project- and time-management methods.
Research, initiate, and plan strategic changes to optimize departmental technologies and personnel.
Recommend and assist with acquiring technology, tools, equipment, and other resources to improve departmental performance and output.
Prioritize and assign employee work, initiate corrective measures to resolve problems, and schedule or adjust overtime requirements as necessary.
Interface with internal and external personnel at diverse levels to maintain effective rapport and resolve issues and inquiries.
Administer and follow corporate and departmental policies, practices, and procedures.
Prepare reports on staffing needs, inventories, statistical analyses, trends, and related matters; analyze data to identify issues and opportunities.
Support non-nursing staff with clinical issues.
Review operational data on assessment triggers, care-plan goals, and goal completion rates.
Consult and collaborate with Medical Consultants, Medical Directors, professional teams, and health care providers to develop treatment plans and goals as needed.