Nurse Team Lead – Clinical Review

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

📋 Description

• Balance case review production with team lead responsibilities according to business needs and staffing levels.

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

• Monitor staff assignments and modify the nurse assignment tool based on staffing, proficiency, request types, and case volumes.

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

• Communicate expectations, assignments, and responsibilities effectively to staff members.

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

• Assist with daily coordination and notifications for physician reviewer cases.

• Monitor team performance, report opportunities to the Supervisor, and serve as a subject matter expert.

• Support staff, resolve issues or conflicts, and foster consistent quality service.

• Collaborate with departments to ensure adherence to protocols and obtain necessary clarifications.

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

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

• Conduct regular one-on-one meetings and provide guidance on process improvement and clinical reviews.

• Identify enhancements in clinical review processes and criteria.

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

• Manage escalated inbound calls or provider requests.

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

• Participate in or lead meetings as directed.

• Develop and implement strategies such as rewards, empowerment, and trust to motivate team members.

• Manage daily phone metrics using AVAYA, ADP Workforcenow, and related systems.

• Collaborate with client personnel to address customer concerns.

• Maintain a thorough understanding of benefit management programs, regulatory requirements, accreditation standards, and client or health-plan service levels.

• Refer complaints to the Compliance Officer and work with Quality to investigate and rectify errors.

• Evaluate and report HIPAA breaches in accordance with policy.

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

• Promote the company's vision, mission, and strategy while encouraging teamwork, respect, diversity, and cooperation.

• Adhere to HIPAA, state and federal regulations, URAC, and NCQA standards.

• Perform other related duties and projects as assigned.

⛳️ Requirements

• Graduate from an accredited nursing school.

• Current active, unrestricted RN or LVN/LPN license from 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, acute care, or managed care settings is preferred.

• Excellent interpersonal, written, and presentation skills are essential.

• Strong leadership and motivational abilities.

• Capability to work in a fast-paced, dynamic environment; on-call after-hours work may be necessary.

• Critical thinking skills are important.

• Experience with team interactions and improvement methods/projects, such as coaching for quality and productivity.

• Understanding of HealthHelp's products and services is beneficial.

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

• Ability to use a telephone, sit, enter data, and view a PC screen for up to 8 hours without assistance.

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

🏝️ Benefits

• Medical, dental, and vision insurance.

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

• 401(k) with company match or other retirement plans.

• Life and AD&D Insurance.

• Employee Assistance Program.

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