Lead Utilization Review (51772)

Job Details Location: Henderson - 1711 Whitney Mesa - Henderson, NV 89014 Position Type: Full Time Education Level: Graduate Degree Salary: $62,053.00 – $62,053.00 Travel: Up to 25% Job Shift: Any Essential Job Functions Provide direct day-to-day oversight, guidance, and supervision to Utilization Review/Utilization Management Support Staff. Serve as the primary clinical escalation point for complex, high-acuity, or disputed cases requiring advanced clinical judgment. Conduct regular one‑on‑one and team meetings to review caseloads, address challenges, and ensure consistent standards of practice. Monitor staff performance and provide timely, constructive feedback; collaborate with the Director of Billing/CIC on formal performance evaluations. Onboard, train, and mentor new UR/UM staff, fostering a culture of clinical excellence, accountability, and professional growth. Identify workflow inefficiencies and implement process improvements in coordination with leadership. Design, develop, and implement comprehensive clinical training programs for UR/UM staff and broader healthcare staff, focusing on documentation best practices, medical necessity criteria, and utilization management. Facilitate training sessions, workshops, and seminars on policy updates, clinical guidelines, payer‑specific requirements, and ASAM criteria. Evaluate the effectiveness of training programs using feedback, documentation audits, and performance metrics; update curricula accordingly. Stay current with industry trends, regulatory changes, and advances in substance use disorder and mental health treatment to maintain accurate training materials. Develop and maintain reference tools, job aids, and documentation templates to support staff in meeting revenue compliance standards. Communicate proactively with internal departments (clinical, billing, case management) to obtain or provide information critical to patient accounts and authorizations. Maintain detailed and thorough system documentation on all accounts. Perform all other related duties as assigned. Qualifications Certifications / Licenses Active clinical licensure in the State of Nevada (e.g., LCSW, LPC, LMFT, or equivalent). Required. Ability to pass first‑level and NABS background clearance. Compliance with vaccinations issued by local, state, federal, or funder requirements will be communicated by Human Resources or appropriate personnel during tenure. Education Master’s degree in Social Work, Counseling, Psychology, or a related clinical field. Required. Experience and Competencies Minimum of two (2) years in a supervisory, lead, or formal leadership role within a clinical, utilization review, or behavioral health setting. Minimum of two (2) years of utilization review and/or billing experience, with demonstrated experience in prior authorization processes, concurrent review, and insurance advocacy. Substantial experience working directly with individuals with substance use disorders and/or co‑occurring mental health disorders. Experience working with Managed Care Organizations (MCOs) and knowledge of ASAM level‑of‑care criteria strongly preferred. Proven experience in conceptualizing a case and creating a clinical impression to present to all involved and approved parties, including managed care representatives. Knowledge of CPT, ICD‑9 & ICD‑10 coding, ASAM, medical terminology, and EMR/CDS systems. Proficiency in Microsoft Office applications and knowledge of HIPAA regulations and guidelines. Knowledge of managed care and reimbursement principles. Understanding and proficiency in State of NV Medicaid Chapter requirements. Strong collaboration, negotiation, and assertiveness skills. Excellent verbal and written communication skills. Critical thinking and problem‑solving skills. Strong analytical skills and ability to analyze, summarize, and effectively present data. Ability to work collaboratively with others in a pleasant and professional manner. Ability to exercise good judgment and discretion. Ability to operate a computer and complete documents in Microsoft program formats. Ability to complete work tasks within scheduled work hours. #J-18808-Ljbffr WestCare Inc