Lead Utilization Review

The Lead Utilization Review & Utilization Management Specialist (Lead UR/UMS) serves as the clinical and operational leader of the Utilization Review/Utilization Management (UR/UM) team. This senior-level position is responsible for providing direct clinical oversight, supervision, and mentorship to UR/UM Support Staff while ensuring the highest standards of clinical review, insurance advocacy, and regulatory compliance across all levels of care.The Lead UR/UMS coordinates and manages the admissions and concurrent review process, including insurance verification, pre-authorization submission, and level-of-care determinations for all treatment levels. This position evaluates the clinical appropriateness, medical necessity, and efficiency of services, and communicates with Managed Care Organizations (MCOs) as a skilled patient advocate, ensuring that the level of care authorized is fully supported by client acuity and aligned with WestCare standards and all applicable regulatory and accrediting requirements.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, with a focus on clinical 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 ensure training materials remain accurate and relevant.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.All other related duties as assignedEssential Qualifications:Certifications/Licenses:Active clinical licensure in the State of Nevada (e.g., LCSW, LPC, LMFT, or equivalent) is required.Ability to pass first level and NABS background clearanceDuring your tenure with WestCare there may be new requirements, including, but not limited to vaccinations that are issued by local, State, Federal, and/or Funders that WestCare may have to comply with. Should this occur Human Resources or appropriate personnel will inform youEducation:Master's degree in Social Work, Counseling, Psychology, or a related clinical field is 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 is required.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 representativesKnowledge of CPT, ICD 9 & ICD 10 coding, ASAM, medical terminology and EMR/CDS Systems.Proficiency in Microsoft Office Platform Applications and knowledge of HIPAA regulations and guidelines.Knowledge of managed care and reimbursement principles.Understanding and proficiency in State of NV Medicaid Chapter requirementsCollaboration, negotiation, and assertiveness skills.Must be organized, detail oriented and have the ability to focus on several job-specific tasks with several potential surrounding distractions and patient traffic.Excellent verbal and written communication skills.Critical thinking and problem solving skills.Must be able to work in a team environment.Ability to perform complex tasks and to prioritize multiple projects.Strong analytical and critical thinking skills and the ability to analyze, summarize, and effectively present data.Ability to work collaboratively with others in a manner that is pleasant and professional.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.Excellent verbal and written communication skills. #J-18808-Ljbffr WESTCARE NEVADA INC