Nurse Team Lead – Clinical Review

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

📋 Description

• Balance case review production with responsibilities as a team lead based on business requirements and staffing levels.

• Conduct assigned case reviews while upholding a minimum target of 3.5 cases per hour during productivity hours.

• Oversee staff assignments and modify the nurse assignment tool according to staffing, proficiency, request type, and case volume.

• Ensure compliance with case turnaround times, client service-level agreements, and regulatory requirements.

• Clearly and professionally communicate expectations, assignments, and responsibilities.

• Serve as a liaison between frontline staff and upper management.

• Assist in daily case coordination and notifications for physician reviewers.

• Monitor team performance, ensure adherence to processes, and report opportunities to the Supervisor.

• Act as a subject matter expert for designated program modalities and procedures.

• Share information and provide support to new and existing staff.

• Evaluate team case work to pinpoint gaps or anomalies.

• Address team member issues or conflicts and foster consistent quality service.

• Collaborate with other departments to ensure protocols are maintained and obtain necessary clarifications.

• Conduct selected case reviews and audits to uncover training opportunities.

• Work with Nursing Management and Clinical Review Training to determine educational and refresher training needs.

• Hold periodic one-on-one meetings with Clinical Review Nurses.

• Identify improvements in clinical review processes and criteria.

• Engage in the HH Nurse Education group email by responding to nurses’ inquiries.

• Provide secondary coverage for Nursing Management during the absence of a Manager or Supervisor.

• Address escalated inbound calls or provider requests.

• Assist with managing inventory, case volumes, and queues.

• Participate in or lead meetings as directed.

• Develop and implement rewards, empowerment, and motivational strategies for team members.

• Promote a healthy, motivating, and inclusive workplace environment.

• Utilize AVAYA, ADP WorkforceNow, and related systems to oversee daily phone metrics.

• Work collaboratively with client personnel to resolve customer issues.

• Maintain an understanding of benefit management programs, regulatory compliance, accreditation standards, and client or health-plan requirements.

• Refer complaints to the Compliance Officer and collaborate with Quality on investigations and corrective actions.

• Assess and report HIPAA breaches in accordance with policy.

• Work with Human Resources to ensure adherence to company policies.

• Advocate for the company’s vision, mission, and strategy.

• Comply with HIPAA, state and federal regulations, as well as URAC and NCQA standards.

• Perform other related duties and projects as assigned.

⛳️ Requirements

• Graduate of an accredited nursing school.

• Current active, unrestricted RN or LVN/LPN license in a state or territory of the United States is required.

• A minimum of 2 years of experience in Utilization Management (UM) is required.

• Additional experience in Quality Management (QM), acute care, or managed care settings is preferred.

• Exceptional interpersonal, written, and presentation skills.

• Ability to interact professionally with facility personnel, providers, members, and internal departments.

• Strong leadership and motivational skills.

• Capability to thrive in a fast-paced, evolving environment.

• Availability for on-call after-hours work may be required.

• Strong critical thinking skills.

• Experience in team interactions and improvement methods/projects, including coaching quality and productivity.

• Familiarity with HealthHelp’s products and services.

• Strong interpersonal and communication capabilities.

• Proficiency in Microsoft Office, including Outlook, PowerPoint, Excel, Word, and Visio.

• Ability to use a telephone for up to 8 hours without assistance.

• Capacity to sit for up to 8 hours unassisted.

• Ability to enter data for up to 8 hours unassisted.

• Capability to view a PC screen for up to 8 hours.

• Ability to prioritize tasks in a multi-task environment.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off (PTO), holidays, and sick leave.

• 401(k) with company match or alternative retirement plan.

• Life and AD&D Insurance.

• Employee Assistance Program.

• Performance-based bonuses, incentive pay, or commissions may be available.