Nurse Team Lead – Clinical Review

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

📋 Description

• Act as the clinical subject matter expert for designated programs and modalities.

• Address nurses' inquiries regarding criteria, guidelines, and processes.

• Carry out prospective case reviews while adhering to Team Lead productivity and quality benchmarks.

• Manage complex, escalated, and expedited cases, including inbound provider calls and requests.

• Analyze HealthHelp clinical guidelines, client medical policies, and regulatory standards.

• Oversee daily physician reviewer case flow and notifications.

• Track case inventory, queues, and turnaround times.

• Modify the nurse assignment tool based on staffing, proficiency, request type, and workload.

• Leverage productivity, turnaround-time, and queue reports to pinpoint backlogs, outliers, and trends.

• Suggest staffing or workflow adjustments to the Supervisor.

• Utilize AVAYA, ADP Workforce Now, and related systems to monitor phone and staffing metrics.

• Review nurse case work for appropriateness, documentation, and denial-related language.

• Assist new nurses through orientation and ramp-up with QA audits and feedback.

• Conduct regular one-on-one meetings with Clinical Review Nurses.

• Propose enhancements to clinical review processes, criteria application, tools, and job aids.

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

• Communicate assignments, expectations, and changes to frontline staff.

• Address or escalate daily issues while promoting a respectful team culture.

• Lead or participate in team meetings.

• Collaborate with departments and client personnel to resolve issues and clarify uncertainties.

• Ensure adherence to benefit management, HIPAA, state and federal regulations, URAC, and NCQA standards.

• Direct complaints to the Compliance Officer and collaborate with Quality to investigate and rectify errors.

• Assess and report HIPAA breaches.

• Carry out other related duties and projects as assigned.

⛳️ Requirements

• Graduate from an accredited nursing school.

• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.

• At least three (3) years of prospective utilization management experience with medical necessity determinations.

• Experience in auditing or reviewing the case work of others, precepting or training new staff, or acting as a clinical resource for a team.

• Consistent performance at or above productivity and quality standards in the current or most recent review position.

• Proficient application of evidence-based criteria such as InterQual, MCG, or proprietary guidelines across multiple programs or modalities.

• Familiarity with utilization management regulatory and accreditation requirements, including URAC, NCQA, CMS, and state turnaround times, Medicare NCDs/LCDs, and denial notice criteria.

• Strong analytical abilities and proficiency in Excel, including sorting, filtering, formulas, and pivot tables.

• Capacity to manage inventory and multiple priorities in a fast-paced, evolving environment.

• Clear and professional written and verbal communication skills, including the ability to provide constructive feedback.

• Proficient in Microsoft Office: Outlook, Excel, Word, and PowerPoint; knowledge of Visio is a plus.

• HIPAA-compliant remote workspace with reliable high-speed internet access.

• Availability for shifts between 7:00 AM and 7:00 PM CT, potentially including late shifts.

• After-hours on-call duty may be necessary.

• Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours.

• Capability 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 plan options.

• Life and AD&D Insurance.

• Employee Assistance Program.

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