Utilization Management Nurse Team Lead

MISSIONOur mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors.VALUESHealthOne is guided by a cultural framework that embodies our values and drives our decisions.Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done.HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals.JOB PURPOSEThe UM Nurse Team Lead ensures efficient, cost effective, and high quality delivery of utilization review service by supporting and training a staff of registered nurses; to oversee the management of medical cases worked by registered nurses; to oversee individual and overall results/outcomes of all cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs.ESSENTIAL JOB DUTIESServe as a clinical and operational team lead for Utilization Management nurses, providing day to day guidance, mentorship, and clinical supportAct as an escalation resource for complex utilization reviews, appeals, and provider/member issues requiring advanced clinical judgmentTrains and develops utilization review staffWorks with Utilization Management Manager to establish and ensure achievement of completion of prior authorization reviews, productivity, and quality goalsInitiate referrals to ensure appropriate coordination of careSeek the advice of the Medical Director when appropriate, according to policyAssists non-clinical staff in performance of administrative reviewsPerforming comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibilityMaintains regular and predictable attendanceConsistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practiceWorks to encourage and promote Company culture throughout the organizationOther duties as may be assignedQUALIFICATIONS3 years Clinical experience preferred2 years of Utilization ReviewProficient in Microsoft Office (Outlook, Word, Excel)Working knowledge of NCQA preferredMust be able to work in an independent and creative mannerAbility to manage multiple projects and prioritiesAdaptive to high pace and changing environmentCustomer service orientedProficient in interpreting benefits, contract language and medical policy/medical review criteriaCurrent, active Compact State license in Nursing (RN)PHYSICAL REQUIREMENTSProlonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required.BENEFITS401K (4% Match, Immediate Vesting)Accident insuranceCompetitive salaryCritical Illness InsuranceDental InsuranceEmployee Assistance ProgramFlexible Spending AccountHealth & Wellness ProgramHealth Savings AccountLife & AD&D InsuranceLong Term DisabilityMedical InsurancePaid Time OffPet InsuranceShort Term DisabilityVision InsurancePRE-EMPLOYMENT SCREENINGDrug Screen and Background Check RequiredHEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYERAll qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status, or any other status protected by state or federal law. #J-18808-Ljbffr