Utilization Management Nurse Team Lead

Health One Alliance•Dalton, GA

19h•Onsite

About The Position

The UM Nurse Team Lead ensures efficient, cost effective, and high quality delivery of utilization review service by supporting and training a staff of registered nurses; to oversee the management of medical cases worked by registered nurses; to oversee individual and overall results/outcomes of all cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs.

Requirements

3 years Clinical experience preferred
2 years of Utilization Review
Proficient in Microsoft Office (Outlook, Word, Excel)
Working knowledge of NCQA preferred
Must be able to work in an independent and creative manner
Ability to manage multiple projects and priorities
Adaptive to high pace and changing environment
Customer service oriented
Proficient in interpreting benefits, contract language and medical policy/medical review criteria
Current, active Compact State license in Nursing (RN)

Responsibilities

Serve as a clinical and operational team lead for Utilization Management nurses, providing day to day guidance, mentorship, and clinical support
Act as an escalation resource for complex utilization reviews, appeals, and provider/member issues requiring advanced clinical judgment
Trains and develops utilization review staff
Works with Utilization Management Manager to establish and ensure achievement of completion of prior authorization reviews, productivity, and quality goals
Initiate referrals to ensure appropriate coordination of care
Seek the advice of the Medical Director when appropriate, according to policy
Assists non-clinical staff in performance of administrative reviews
Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned