Clinical Team Lead, Utilization Management

This is a fully remote position, open to applicants in Illinois.

📋 Description

• Evaluate reports for assignments, trends, metrics, and issues.

• Act as the primary contact for frontline staff inquiries regarding cases.

• Supervise RN/MD rounds as necessary.

• Assist with escalated case evaluations and facility-related matters.

• Collect clinical data and apply clinical criteria, guidelines, policies, procedures, and judgment to make coverage decisions or recommendations.

• Coordinate communication with providers and other parties to facilitate care and treatment.

• Identify members for referral opportunities involving additional products, services, or programs.

• Recognize opportunities to enhance healthcare service quality and promote effective benefit utilization.

• Provide consultation and expertise to both internal and external stakeholders in the coordination and administration of utilization and benefit management.

• Carry out work in a standard office setting while meeting productivity and quality standards.

⛳️ Requirements

• Minimum of 3 years of experience as a Registered Nurse in an adult acute care or critical care environment.

• Active, current, and unrestricted RN license in the state of residence.

• Willingness to work weekends, holidays, and evening shifts in a 24/7 environment.

• Experience in Managed Care is preferred, particularly in Utilization Management.

• Preferred candidates should reside in Central time zones.

• Associate or Bachelor of Science in Nursing; BSN is preferred.

• Proficient computer skills, including the ability to navigate multiple systems and keyboard efficiently.

• Strong verbal and written communication skills.

• Capability to multitask, prioritize, and adapt to a dynamic, fast-paced environment.

• Ability to closely inspect handwritten and computer-generated documents and PC monitors.

• Capacity to sit for extended periods, engage in telephone conversations, and type on a computer.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.