Nurse Team Lead - Clin Rev
Core
Clinical subject matter expert for prospective utilization review, resolving complex criteria/guideline questions, auditing/coaching nurse reviewers, and managing case inventory/turnaround times.
Role type
Senior IC nurse team lead (utilization management)
Builds
Medical necessity determinations and utilization review decisions for health plans/employers
Domain
Healthcare administration / Utilization Management
Required skills
Prospective utilization management, clinical auditing, team coaching, regulatory compliance (URAC/NCQA/CMS), evidence-based criteria application (InterQual/MCG), inventory management, data analysis (Excel), stakeholder communication
Preferred skills
Specialty program experience (Imaging/Cardiology/Oncology), workforce/inventory tools, denial letter language, UM certifications (CPUM/CPUR/CCM/CPHQ), multistate license
Technologies
AVAYA, ADP Workforce Now, Microsoft Office (Excel, Outlook, Word, PowerPoint, Visio), case assignment tools
Responsibilities
Perform prospective case reviews and handle escalated/expedited cases; audit nurse work and identify training needs; monitor case inventory/queues and adjust staffing; interpret clinical guidelines and regulatory requirements; provide secondary management coverage; coordinate physician reviewer case flow
Seniority
Senior, hands-on IC with lead duties