Utilization Review Clinical Team Lead

Sedgwick

6d • Onsite

About The Position

To provide services for dedicated accounts; to ensure the efficient, cost effective, and high quality delivery of utilization review service by supervising 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

• Active unrestricted RN license in a state or territory of the United States required.
• Six (6) years of clinical practice experience or equivalent combination of education and experience required to include two (2) years of supervisory experience.
• Strong knowledge of utilization review practices
• Expert knowledge of the insurance industry and claims processing
• Acquired knowledge of GM claims process, plan design and customer needs
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Leadership/management/motivational skills
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

Nice To Haves

• Bachelor's degree from an accredited college or university preferred.
• CPUR or other related designation preferred.

Responsibilities

• Trains and develops utilization review staff.
• Supervises a team of nurses ensuring utilization management services are delivered promptly, cost effectively, courteously, and according to legal requirements, operational, and quality assurance standards.
• Takes corrective action when necessary ensuring objectives, standards, policies and procedures are met.
• Works with program manager to establish and ensure achievement of office/unit customer service, utilization patterns, productivity, quality and financial goals.
• Ensures that staff adheres to quality assurance and productivity standards: assists program manager in evaluating customer service utilization patterns, productivity, quality and financial results ensuring that service delivery is within parameters defined by the company.
• Performs active customer service function for account; provides day-to-day contact with customer to resolve service delivery problems/issues; responds to customer requests; communicates any special customer instruction or procedure that must be adhered to by the registered nurse.
• Advises staff of any pertinent changes in customer service delivery, regulatory mandates or business functions; provides training on regulatory issues.
• Makes recommendation for ongoing and future service delivery options; identifies referrals for case management.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Administers company personnel policies in all areas and follows company staffing standards and training recommendations.
• Interviews, hires and establishes colleague performance development plans; conducts colleague performance reviews.
• Provides support, guidance, leadership and motivation to promote maximum performance.

Benefits

• Three Medical, and two dental plans to choose from.
• Tuition reimbursement eligible.
• 401K plan that matches 50% on every $ you put in up to the first 6% you save.
• 4 weeks PTO your first full year.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager