Utilization Management Team Lead

Trinity Health

28d

About The Position

The UM Lead is responsible for overseeing day-to-day activities within the Utilization Management (UM) department, including staffing, assignment management, and serving as the first line of escalation for problem-solving. This role ensures effective leadership and delegation of daily UM activities and workflows. The UM Lead is also responsible for intervening with payers to prevent denial escalation, managing in-house expedited appeals, and conducting medical reviews for post-claim audits. As a resource and mentor to the UM staff, the UM Lead provides education on payer requirements, regulations, and standard work practices. This role involves collaboration with the Director of Care Coordination/Case Management and a multidisciplinary team.

Requirements

Comprehensive knowledge of Utilization Management, typically gained through a bachelor’s degree in Nursing, Healthcare Administration, or a related field, or equivalent relevant UM work experience.
A minimum of 5 years of Utilization Management experience.
Current Registered Nurse License in the State of Iowa required.
Comfortable working in a collaborative, shared leadership environment.
Strong personal presence characterized by honesty, integrity, and a caring attitude, with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

Nice To Haves

Previous leadership experience preferred.
Certification in Utilization Management preferred.

Responsibilities

Facilitates daily activities of the UM department and provides leadership to the team.
Assists the Director in hiring, training, coaching, and evaluating personnel.
Works with healthcare providers to assess medical necessity and appropriateness of inpatient admissions, providing feedback on documentation to support these decisions.
Collaborates with the team to maximize financial reimbursement for MercyOne Central Hospital through accurate and timely clinical documentation.
Coordinates with the Pre-service Team to ensure pre-certification for patients with complex diagnoses or care settings, in accordance with payer requirements.
Maintains strong relationships with insurance payers to facilitate authorization approvals.
Collaborates with the Revenue Cycle, HIM, Denials, and Finance teams.
Demonstrates effective communication (verbal, written, and digital) in various forms including medical records, emails, and phone calls.
Consults with other professionals to improve patient outcomes.
Effectively delegates tasks to other UM team members and evaluates their performance.
Completes assigned learning materials and competency activities within orientation and beyond.
Contributes to the professional growth of others by serving as a preceptor, coach, and mentor.
Assists in managing resources to meet quality and financial goals.
Performs other duties as assigned by the manager.
Maintains knowledge of relevant federal, state, and local regulations, as well as Trinity Health’s Organizational Integrity Program, Standards of Conduct, and other policies to ensure adherence.