Utilization Review (UR) Clinical Lead
About The Position
The Utilization Review (UR) Clinical Lead is responsible for overseeing and guiding the utilization review process to ensure medical necessity, regulatory compliance, and appropriate use of healthcare resources. This role provides clinical leadership to the UR team, supports compliance with federal and state regulations, and serves as a clinical resource for complex cases and payer interactions. The UR Clinical Lead works collaboratively with providers, care teams, and leadership to promote high-quality, cost-effective patient care while maintaining adherence to organizational policies and payer requirements.
Requirements
- Active, unrestricted clinical license (RN, LPN, or other applicable clinical license, depending on organization needs)
- Minimum of 10+ years of clinical experience
- Experience in utilization review, case management, or utilization management
- Strong knowledge of medical necessity criteria (e.g., InterQual, MCG, or similar)
- Excellent communication, documentation, and critical-thinking skills
- Responsive and client focused
- Be an effective liaison between client, stakeholders and vendor teams
- Strong clinical judgment and decision-making
- Ability to balance patient care quality with regulatory and payer requirements
- Detail-oriented with strong organizational skills
- Collaborative, solution-focused leadership style
- Comfortable navigating sensitive clinical and compliance-related discussions
Nice To Haves
- Prior leadership or lead experience
- Experience working with Medicaid, Medicare, and commercial payers
- Knowledge of behavioral health and/or specialty care utilization review (if applicable)
- Certification in Case Management or Utilization Review (e.g., CCM, URAC)
Responsibilities
- Provide day-to-day clinical leadership and guidance to the Utilization Review team with current case management experience
- Serve as a subject matter expert for utilization management standards, medical necessity criteria, and payer requirements
- Review complex, high-risk, or escalated cases and provide clinical recommendations
- Support consistent and accurate application of UR policies and procedures
- Assist in the development, documentation, and maintenance of UR workflows and standard operating procedures
- Oversee concurrent, retrospective, and prospective utilization reviews
- Ensure documentation supports medical necessity and level-of-care determinations
- Monitor authorization processes, denials, appeals, and peer-to-peer reviews
- Identify trends in denials and collaborate on corrective actions
- Ensure compliance with CMS, Medicaid, commercial payer, and accreditation standards (e.g., Joint Commission, NCQA, CARF, as applicable)
- Participate in audits, quality reviews, and regulatory readiness activities
- Maintain up-to-date knowledge of utilization management regulations and best practices
- Act as a liaison between UR staff, providers, care coordination teams, and leadership
- Support provider education related to documentation, medical necessity, and payer requirements
- Collaborate with Quality, Compliance, and Revenue Cycle teams to optimize outcomes
- Assist with onboarding and training of UR staff
- Provide mentoring, coaching, and ongoing clinical education
- Contribute to policy development and process improvement initiatives
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
11-50 employees
