Position Summary
The Clinical Team Lead in the Utilization Management team utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
What you will do
- Analyzes reports for assignments/trends/metrics/issues.
- First in line for questions from frontline staff on cases.
- May be required to proctor RN/MD rounds.
- Assists with escalated case reviews/facility issues.
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care.
- Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs.
- Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
- Typical office working environment with productivity and quality expectations.
- Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
- Sedentary work involving periods of sitting, talking, listening.
- Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
- Effective communication skills, both verbal and written.
Required Qualifications
- 3+ years of experience as a Registered Nurse in adult acute care/critical care setting.
- Must have active current and unrestricted RN licensure in state of residence.
- Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.
Preferred Qualifications
- Managed Care experience preferred, especially Utilization Management.
- Preference for those residing in Central time zones.
Education
- Associate or Bachelor of Science in Nursing (BSN preferred).
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is
$66,575.00 - $142,576.00