Nurse Team Lead - Clin Rev

POSITION SUMMARY

The Clinical Review Team Lead is the team’s clinical subject matter expert for prospective utilization review. The Team Lead resolves complex criteria and guideline questions, audits and coaches nurse reviewers, manages daily case inventory and turnaround times, and performs case reviews as assigned.

This is a working lead role: the Team Lead balances production review with lead duties based on business needs and staffing and provides secondary coverage for the Supervisor. The ideal candidate is a proven high-performing reviewer who is analytical, highly organized and able to teach others.

MAJOR RESPONSIBILITIES

Clinical expertise and case review

• Serves as the clinical subject matter expert for assigned programs and modalities, answering nurses’ criteria, guideline and process questions, including through the team’s clinical education mailbox.
• Performs prospective case reviews as assigned and maintains the established Team Lead productivity (cases per hour) and quality standards during production hours.
• Handles complex, escalated and expedited cases and escalated inbound provider calls and requests.
• Interprets HealthHelp clinical guidelines, client medical policies and regulatory requirements for the team, and identifies guideline gaps or inconsistencies for Nursing Management.
• Coordinates daily physician reviewer case flow and notifications.
Workflow and inventory

• Monitors case inventory, queues and turnaround times throughout the day, and adjusts the nurse assignment tool based on staffing, proficiency, request type and volume so client service levels and regulatory turnaround times are met.
• Uses productivity, turnaround-time and queue reports to identify backlogs, outliers and trends, and recommends staffing or workflow changes to the Supervisor.
• Uses AVAYA, ADP Workforce Now and related systems to manage daily phone and staffing metrics.
Quality, training and coaching

• Audits nurse case work for appropriateness of determinations, documentation and denial-related language, and identifies individual and team training needs.
• Supports new nurses through orientation and ramp, including QA audits and feedback, in coordination with Nursing Management and the Clinical Review Training Department.
• Conducts regular one-on-ones with Clinical Review Nurses on review quality, productivity and process.
• Recommends improvements to clinical review processes, criteria application, tools and job aids.
Team support and communication

• Provides secondary Nursing Management coverage when the Supervisor or Manager is unavailable.
• Communicates assignments, expectations and changes clearly and professionally, and acts as liaison between frontline staff and management.
• Listens to team feedback, resolves day-to-day issues or escalates them, and fosters a respectful, motivating team environment.
• Leads or participates in team meetings as directed.
• Collaborates with other departments and client personnel to resolve concerns and obtain clarifications.
STANDARD DEPARTMENTAL RESPONSIBILITIES

• Knows the requirements of each assigned benefit management program, including regulatory compliance, accreditation standards, and client service levels by line of business and geographic region.
• Refers complaints to the Compliance Officer as appropriate and works with the Quality Department to investigate and correct errors.
• Evaluates and reports HIPAA breaches according to policy.
• Collaborates with Human Resources to ensure adherence to company policies.
• Adheres to all HIPAA, state and federal regulations and to URAC and NCQA standards pertinent to the role.
• Performs other related duties and projects as assigned.
This job description is not designed to cover or contain a comprehensive list of activities, duties or responsibilities required of the employee. Duties, responsibilities and activities may change at any time with or without notice.

Function: Production
Experience Level: Mid-Senior Level