Nurse Team Lead - Clinical Review

Job Description

POSITION SUMMARY

The Clinical Review Team Lead is the team’s clinical subject matter expert for prospective utilization review. The Team Lead resolves complex criteria and guideline questions, audits and coaches nurse reviewers, manages daily case inventory and turnaround times, and performs case reviews as assigned.

This is a working lead role: the Team Lead balances production review with lead duties based on business needs and staffing and provides secondary coverage for the Supervisor. The ideal candidate is a proven high-performing reviewer who is analytical, highly organized and able to teach others.

MAJOR RESPONSIBILITIES

Clinical expertise and case review

• Serves as the clinical subject matter expert for assigned programs and modalities, answering nurses’ criteria, guideline and process questions, including through the team’s clinical education mailbox.
• Performs prospective case reviews as assigned and maintains the established Team Lead productivity (cases per hour) and quality standards during production hours.
• Handles complex, escalated and expedited cases and escalated inbound provider calls and requests.
• Interprets HealthHelp clinical guidelines, client medical policies and regulatory requirements for the team, and identifies guideline gaps or inconsistencies for Nursing Management.
• Coordinates daily physician reviewer case flow and notifications.

Workflow and inventory

• Monitors case inventory, queues and turnaround times throughout the day, and adjusts the nurse assignment tool based on staffing, proficiency, request type and volume so client service levels and regulatory turnaround times are met.
• Uses productivity, turnaround-time and queue reports to identify backlogs, outliers and trends, and recommends staffing or workflow changes to the Supervisor.
• Uses AVAYA, ADP Workforce Now and related systems to manage daily phone and staffing metrics.

Quality, training and coaching

• Audits nurse case work for appropriateness of determinations, documentation and denial-related language, and identifies individual and team training needs.
• Supports new nurses through orientation and ramp, including QA audits and feedback, in coordination with Nursing Management and the Clinical Review Training Department.
• Conducts regular one-on-ones with Clinical Review Nurses on review quality, productivity and process.
• Recommends improvements to clinical review processes, criteria application, tools and job aids.

Team support and communication

• Provides secondary Nursing Management coverage when the Supervisor or Manager is unavailable.
• Communicates assignments, expectations and changes clearly and professionally, and acts as liaison between frontline staff and management.
• Listens to team feedback, resolves day-to-day issues or escalates them, and fosters a respectful, motivating team environment.
• Leads or participates in team meetings as directed.
• Collaborates with other departments and client personnel to resolve concerns and obtain clarifications.

STANDARD DEPARTMENTAL RESPONSIBILITIES

• Knows the requirements of each assigned benefit management program, including regulatory compliance, accreditation standards, and client service levels by line of business and geographic region.
• Refers complaints to the Compliance Officer as appropriate and works with the Quality Department to investigate and correct errors.
• Evaluates and reports HIPAA breaches according to policy.
• Collaborates with Human Resources to ensure adherence to company policies.
• Adheres to all HIPAA, state and federal regulations and to URAC and NCQA standards pertinent to the role.
• Performs other related duties and projects as assigned.

This job description is not designed to cover or contain a comprehensive list of activities, duties or responsibilities required of the employee. Duties, responsibilities and activities may change at any time with or without notice.

Qualifications

QUALIFICATIONS

Required

• Graduate of an accredited school of nursing.
• Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory.
• Minimum of three (3) years of prospective utilization management experience making medical necessity determinations (prior authorization, pre-service review or precertification) at a health plan, utilization management organization, or specialty or radiology benefit manager.
• Experience auditing or reviewing other reviewers’ case work, precepting or training new staff, or serving as a go-to clinical resource for a team.
• Sustained performance at or above productivity and quality (QA audit) standards in the current or most recent review role.
• Expert application of evidence-based criteria (e.g., InterQual, MCG, or proprietary guidelines) across more than one program or modality, with the ability to explain the clinical rationale to nurses and providers.
• Working knowledge of utilization management regulatory and accreditation requirements, including URAC, NCQA, CMS and state turnaround times, Medicare NCDs/LCDs, and denial notice requirements.
• Strong analytical skills: uses Excel (sorting, filtering, formulas, pivot tables) and operational reports to monitor productivity, queues and turnaround times and to spot trends.
• Highly organized, with the ability to manage inventory and multiple priorities in a fast-paced, changing environment.
• Clear, professional written and verbal communication, including giving constructive feedback.
• Proficiency in Microsoft Office (Outlook, Excel, Word, PowerPoint; Visio a plus).

Preferred

• Review experience in two or more specialty program areas (e.g., Diagnostic Imaging, Cardiology, Musculoskeletal, Physical Medicine, Sleep, Oncology, Radiation Therapy, Genetic Testing).
• Formal team lead, QA auditor, trainer or preceptor role within a utilization management department.
• Experience with workforce or inventory tools such as a case assignment tool, AVAYA or ADP Workforce Now.
• Knowledge of adverse determination and denial letter language requirements.
• UM or quality certification (e.g., CPUM, CPUR, CCM or CPHQ).
• Multistate (compact) nursing license.

ENVIRONMENT AND PHYSICAL DEMANDS

• HIPAA-compliant remote location with reliable high-speed internet.
• Shift assigned within HealthHelp’s utilization management operating hours of 7:00 AM–7:00 PM CT, which may include a late shift; after-hours on-call may be required.
• Ability to use the telephone, sit, enter data and view a PC screen for up to 8 hours.
• Ability to prioritize in a multi-task environment

Additional Information

Shift 10:30am - 7:00pm

Compensation Disclosure

The base salary for this position is LVN/LPN Team Lead $74,880 and RN Team Lead $85,280 annually. This represents the base pay range that we reasonably expect to offer for this position.
In addition to base pay, this role may be eligible for performance-based bonuses, incentive pay, or commissions, which are not included in the listed base salary range.

WNS complies with all applicable federal, state, and local pay transparency laws, including those in California, Colorado, New York, Washington, and Illinois.

Note: For complete compensation information, please refer to the job posting on our official careers page.

Equal Opportunity Employer Statement

WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process.

Benefits Overview

Our benefits package includes (but is not limited to):

- Medical, dental, and vision insurance

- Paid time off (PTO), holidays, and sick leave

- 401(k) with company match or other retirement plan

- Life and AD&D Insurance

- Employee Assistance Program

Equal Opportunity Employer Statement

WNS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other status protected under federal, state, or local law.

We also provide reasonable accommodations to individuals with disabilities and for sincerely held religious beliefs in all aspects of employment, including the application process.

How to Apply

Please submit your application, including a resume and optional cover letter, through our careers page or email to [email protected].