Utilization Review Specialist Team Lead

Verida Inc•Villa Rica, GA

7d•Onsite

About The Position

Onsite Villa Rica GA Lead and manage the Utilization Review team that reviews member transportation requests outside contractual mileage guidelines and non‑covered Medicaid services/locations. Ensure timely, accurate, compliant decisions; oversee subscription/standing‑order program operations; handle escalations, quality assurance, reporting, and staff development.

Requirements

Strong knowledge of Medicaid and Medicare rules and transportation/non‑emergency medical transport (NEMT) processes; familiarity with dialysis and nursing home placement a plus.
Proven supervisory experience with ability to manage, mentor, and motivate staff in a high‑volume, high‑stress environment.
Excellent written and verbal communication, conflict resolution, and interpersonal skills for sensitive situations.
Strong analytical and sound judgment skills; ability to make consistent, well‑documented decisions.
Proficient with Microsoft Word and Excel; familiarity with utilization review preferred.
Highly organized, self‑directed, flexible, and able to manage competing priorities across internal and external stakeholders.
High school diploma or equivalent required; Associate’s degree or higher in healthcare administration, nursing, social work, or related field preferred.
Minimum 3–5 years’ experience in healthcare utilization review, customer service in healthcare, NEMT, or related operations, with at least 1–2 years in supervisory or lead role.

Nice To Haves

Experience working with Medicaid programs, community resources, dialysis providers, and long‑term care placement preferred.

Responsibilities

Supervise daily operations of the Utilization Review (UR) team: assign work, monitor throughput, ensure quality and adherence to policy and contractual guidelines.
Review and approve/deny complex or escalated transportation requests outside mileage guidelines and requests to non‑covered services/locations when delegated.
Oversee review and enrollment of facilities into the Subscription/Standing Order Transportation Program for NEMT.
Supervise issuance of Member Warning Letters as appropriate.
Ensure timely completion and accuracy of departmental reporting: daily denial letters, member no‑show letters, monthly denial summary; review and submit the Monthly Denial Summary Report to clients/regions.
Develop, implement and maintain standard operating procedures, decision criteria, and quality controls for UR processes.
Train, coach, and evaluate UR Specialists; conduct performance reviews, corrective action, and career development planning.
Monitor key performance indicators (turnaround time, accuracy/appeals rate, denial justification, report timeliness) and implement process improvements to meet contractual agreements.
Serve as primary escalation point for internal departments, external healthcare providers, and client inquiries; represent UR in cross‑functional meetings.
Maintain confidentiality and ensure compliance with Medicaid/Medicare rules, state regulations, contractual obligations, and HIPAA.
Participate in audits and support remediation activities; prepare executive summaries and trend analyses for leadership.