Utilization Review RN Team Lead
About The Position
The Utilization Review (UR) Nurse Team Lead provides clinical and operational leadership to support the UR nursing team in completing accurate, timely, and compliant medical necessity reviews. This role provides day-to-day oversight of workflow management, quality assurance, staff development, and onboarding activities. The Team Lead ensures adherence to established clinical criteria, regulatory requirements, and client-specific expectations. The Team Lead collaborates with the Director of Utilization Management, supports client implementation and communication efforts, and serves as a subject matter expert in utilization review processes, including admission and continued stay determinations. The position requires strong clinical judgment, leadership skills, and expertise in acute care utilization management to promote high-quality outcomes and operational excellence.
Requirements
- Proficient in multiple Electronic Health Records and case management systems
- Strong communication skills. Communicates clearly and concisely, verbally and in writing
- Demonstrated ability to coach and mentor others
- Ability to thrive in a fast-paced environment and adapt to frequent changing business needs
- Ability to work independently, needing minimal supervision.
- Advanced level of experience with InterQual and/or MCG within the last two years
- Experience in Microsoft Suite including Office and basic Excel
- Graduate of an accredited school of nursing
- Current, unrestricted Registered Nurse (RN) license.
- Minimum five (5) years of acute care nursing experience in a hospital setting
- Minimum three (3) years of recent hospital-based or health plan acute utilization review experience
- Advanced experience with acute admission reviews and continued stay reviews
Nice To Haves
- Bachelor’s of Science in Nursing (BSN)
- Certified Case Manager (CCM), Accredited Case Manager (ACM), or Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC)
Responsibilities
- Support UR nurses in conducting hospital admission and continued stay reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient) using approved clinical criteria and guidelines, such as InterQual® and/or MCG®.
- Oversee daily team workflow to ensure UR nurses complete assigned reviews accurately and in order of established priorities.
- Audit UR nurse reviews for accuracy, completeness, and compliance with client-specific processes and requirements.
- Provide ongoing feedback, coaching, and performance guidance to the UR nurse team.
- Support training and onboarding of new UR nurses.
- Support client onboarding and assist with client communication and follow up.
- Perform other duties as assigned by the Director of Utilization Management.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
