UTILIZATION REVIEW NURSE (RN) - TEAM LEAD
About The Position
If you’re an experienced utilization review nurse looking for the next step in your career, this is an opportunity to lead meaningful work that directly impacts patient care, regulatory excellence, and organizational performance. In this role, you’ll have the chance to combine your clinical expertise with leadership responsibilities, helping guide a team, support sound admission status decisions, prevent avoidable denials, and improve patient throughput. For professionals motivated by influence, collaboration, and the ability to make a measurable difference, this position offers both purpose and professional growth. Premier Health offers the opportunity to work in a highly collaborative environment where your voice and experience matter. As the Utilization Review Nurse - Team Lead, you will serve as both a clinical expert and an operational leader, supporting staff development, mentoring team members, and partnering closely with physicians, case management, CDI, coding, and revenue cycle teams. This role is ideal for a nurse who values teamwork, process improvement, and the opportunity to shape outcomes across the continuum of care. Premier Health has built a strong reputation as a respected healthcare employer, known for its commitment to quality, patient-centered care, and professional excellence. Team members are valued for their expertise and dedication, and leaders are empowered to contribute to a culture of accountability, support, and continuous improvement. In this role, you will feel connected not only to your immediate team, but also to the broader mission of delivering the right care at the right time while maintaining compliance and optimizing reimbursement. Employees in healthcare leadership and clinical support roles often value the sense of purpose, collaboration, and trust they experience when working with a strong interdisciplinary team. In this position, you’ll be part of a professional environment where relationships matter, expertise is respected, and your leadership helps others succeed. If you enjoy mentoring peers, solving complex utilization challenges, and driving best practices in regulatory compliance and denial prevention, this role can offer a highly rewarding next step. The Utilization Review Nurse Team Lead serves as the clinical and operational leader for the UR team, ensuring appropriate patient status, medical necessity compliance, denial prevention, and regulatory adherence while supporting staff development and performance. The UR Nurse Team Lead provides day-to-day oversight of utilization review activities, including medical necessity reviews, admission status determinations, payer communications, denial management, and regulatory compliance. The Team Lead acts as a clinical resource for staff, collaborates with physicians, case management, CDI, Coding, and revenue cycle teams, and promotes efficient patient throughput while optimizing reimbursement and reducing avoidable denials.
Requirements
- Bachelor’s degree required
- Valid RN license in the State of Ohio required
- 3–5 years of job-related experience required
- Previous experience as a Utilization Review Nurse required
- Exemplary interpersonal skills with the ability to build and maintain rapport with physicians and Integrative Care Team members
- Strong negotiation, conflict resolution, and assertive communication skills
- Proficiency in Microsoft Office required
Nice To Haves
- Certification in a clinical specialty such as case management, utilization review, critical care, or rehab preferred
- Knowledge of InterQual ISD-A and Milliman Guidelines preferred
- Knowledge of third-party insurance requirements preferred
Responsibilities
- Serves as the primary review resource for UR nurses
- Assists with orientation and mentoring of new staff
- Assist manager with staffing, scheduling, and workload distribution
- Assists with facilitating team huddles and with staff meetings
- Provide guidance on admission status determination
- Assist staff with complex medical reviews using CMS and payer-specific criteria
- Support escalation of cases to the physician advisor team
- Monitor compliance with the Two-Midnight rule and payer-specific requirements
- Identify trends leading to medical necessity and level of care denials
- Collaborate with physician advisors and revenue cycle teams to reduce denials
- Participate in denial reviews and appeal preparation
- Participate in regular audits of UR staff for accuracy of status assignment, clinical review integrity, and productivity
- Participate in denial data entry and collection
- Ensure compliance with CMS regulations, Medicare Conditions of Participation, commercial payer requirements, and state and accreditation standards
- Support audit readiness and regulatory reviews
- Track key performance indicators including initial review timeliness, continued stay review compliance, observation to inpatient conversion rates, and denial rates
- Lead or participate in performance improvement initiatives focused on throughput, status accuracy, and denial reduction
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
