Team Lead, Clinical Care Review

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

📋 Description

• Oversee Clinical Care Review staff and manage daily operations within the CCR team.

• Ensure that direct reports achieve minimum standards for quality and productivity.

• Evaluate health conditions and the complexities of services provided.

• Create workload management strategies informed by trend analysis and advocate for the CCR team.

• Offer feedback, guidance, training, and ongoing resources to CCRs and the pre-authorization team.

• Standardize reporting on activities and outcomes for departmental initiatives and programs, including documentation required by state authorities and accrediting organizations.

• Conduct utilization review and discharge planning activities for CareSource members.

• Supervise the effective and economical delivery of healthcare services.

• Contribute to process improvement initiatives and enhance processes that support cost-efficient utilization and appropriate care levels.

• Collaborate with Care Management, Claims, Enrollment, Customer Service, and other departments to resolve issues.

• Audit CCR team members to ensure compliance with CareSource policies, procedures, regulatory standards, NCQA guidelines, and URAC guidelines.

• Provide insights for team evaluations and aid in the development of team goals.

• Design and deliver informational sessions on utilization management.

• Attend state hearings as necessary.

• Execute other duties as assigned.

⛳️ Requirements

• A graduate-level degree in mental health or a Bachelor of Science in Nursing, or equivalent years of relevant experience is required.

• At least one year of experience in Utilization Management/Utilization Review is required.

• A current, unrestricted license as a Registered Nurse (RN) or a mental health professional (e.g., LPC, LCSW) is mandatory.

• A minimum of five years of clinical experience is preferred.

• Experience as a Certified Care Manager is preferred.

• Basic computer skills are necessary.

• Proficiency in Microsoft Word and Excel is required.

• Management skills are essential.

• Previous supervisory experience is required.

• Ability to work both independently and as part of a team is crucial.

• Familiarity with the healthcare sector is beneficial.

• Strong critical listening and analytical thinking skills are necessary.

• Skills in training and teaching are important.

• Experience in negotiation is preferred.

• Leadership experience and capabilities are essential.

• A Compact RN license or Multi-state Counselor/Social Worker license is preferred.

• MCG Certification is preferred.

🏝️ Benefits

• Bonus opportunities linked to both company and individual performance may be available.

• A substantial and comprehensive total rewards package is offered.

• Comprehensive support for employee well-being is provided.