Nurse Team Lead – Clinical Review

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

📋 Description

• Balance the review of cases with team leadership responsibilities according to business demands and staffing levels.

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

• Oversee staff work assignments and modify the nurse assignment tool based on staffing levels, skill proficiency, request types, and case volume.

• Ensure adherence to case-specific turnaround times in relation to client service level agreements and regulatory compliance mandates.

• Clearly communicate expectations, assignments, and responsibilities to team members.

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

• Assist in the daily coordination and notifications for physician reviewer cases.

• Monitor team performance, identify areas for improvement, and ensure adherence to established processes.

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

• Distribute information and provide support to both new and existing staff members.

• Assess team member case work to detect gaps or anomalies.

• Listen to team feedback and address any issues or conflicts that arise.

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

• Conduct specific case reviews and audits to pinpoint 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 enhancements to clinical review processes and criteria.

• Engage in the HH Nurse Education group email and address inquiries regarding cases and clinical review processes.

• Provide secondary Nursing Management coverage during the absence of a manager or supervisor.

• Manage escalated inbound calls or provider requests effectively.

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

• Participate in or lead meetings as required.

• Develop and implement strategies focused on rewards, empowerment, trust, and other motivators to inspire team members.

• Foster a positive and motivating work environment.

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

• Collaborate with client personnel to address and resolve customer concerns.

• Maintain up-to-date knowledge of benefit management programs, regulatory compliance, accreditation standards, and client or health-plan service-level requirements.

• 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.

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

• Promote teamwork, respect, diversity, and cooperation among team members.

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

• Perform additional related duties and projects as assigned.

⛳️ Requirements

• Graduate of an accredited nursing program.

• Must possess a current active, unrestricted RN or LVN/LPN license in a state or territory of the United States.

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

• At least 1 year of supervisory experience is necessary.

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

• Proficient critical thinking skills.

• Experience with team interactions and improvement initiatives, such as coaching for quality and productivity.

• Familiarity with HealthHelp’s products and services.

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

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

• Ability to sit for up to 8 hours without assistance.

• Ability to enter data for up to 8 hours without assistance.

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

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

🏝️ Benefits

• Medical, dental, and vision insurance coverage.

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

• 401(k) plan with company matching or other retirement options.

• Life and AD&D insurance coverage.

• Employee Assistance Program available.

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

• Reasonable accommodations for individuals with disabilities and sincerely held religious beliefs.