Nurse Team Lead – Clinical Review

• Balance case review production with team lead duties based on business needs and staffing levels
• Conduct assigned case reviews while maintaining a minimum target of 3.5 cases per hour during productivity hours
• Monitor staff assignments and adjust the nurse assignment tool based on staffing, proficiency, request types, and case volumes
• Ensure case-specific turnaround times, client service-level agreements, and regulatory compliance requirements are met
• Communicate expectations, assignments, and responsibilities to staff
• Act as liaison between frontline staff and upper management
• Assist with daily physician reviewer case coordination and notifications
• Monitor team performance, report opportunities to the Supervisor, and serve as a subject matter expert
• Support staff, resolve issues or conflicts, and promote consistent quality service
• Collaborate with departments to ensure protocols are followed and obtain clarifications
• Conduct selected case reviews and audits to identify training opportunities
• Coordinate with Nursing Management and Clinical Review Training to identify educational and refresher training needs
• Conduct periodic one-on-ones and provide process-improvement and clinical-review guidance
• Identify improvements in clinical review processes and criteria
• Provide secondary Nursing Management coverage during Manager or Supervisor unavailability
• Handle escalated inbound calls or provider requests
• Assist with inventory management, case volumes, and queues
• Participate in or conduct meetings as directed
• Develop and use rewards, empowerment, trust, and other strategies to motivate team members
• Manage daily phone metrics using AVAYA, ADP Workforcenow, and related systems
• Collaborate with client personnel to resolve customer concerns
• Maintain knowledge of benefit management programs, regulatory requirements, accreditation standards, and client or health-plan service levels
• Refer complaints to the Compliance Officer and collaborate with Quality to investigate and correct errors
• Evaluate and report HIPAA breaches according to policy
• Collaborate with Human Resources on company-policy adherence
• Promote the company vision, mission, and strategy while fostering teamwork, respect, diversity, and cooperation
• Adhere to HIPAA, state and federal regulations, URAC, and NCQA standards
• Perform other related duties and projects as assigned

• Graduate of an accredited school of nursing
• Current active, unrestricted RN or LVN/LPN license in a state or territory of the United States required
• Minimum of 2 years of Utilization Management (UM) experience required
• Additional experience in QM, acute care, or managed care setting preferred
• Excellent interpersonal, written and presentation skills
• Leadership and motivational skills
• Ability to work in a fast-paced, evolving environment; on-call after-hours work may be required
• Critical thinking skills
• Experience in team interactions and improvement methods/projects, such as coaching quality and productivity
• Understanding of HealthHelp’s products and services
• Knowledge of Microsoft Office, including Outlook, PowerPoint, Excel, Word, and Visio
• Ability to use telephone, sit, enter data, and view a PC screen for up to 8 hours unassisted
• Ability to prioritize in a multi-task environment

• Medical, dental, and vision insurance
• Paid time off (PTO), holidays, and sick leave
• 401(k) with company match or other retirement plan
• Life and AD&D Insurance
• Employee Assistance Program
• Performance-based bonuses, incentive pay, or commissions may be available