Team Lead, Utilization Management - MSL with UM experience (PST Hours required)

Job Summary:

The Team Lead, Clinical Care Review is responsible for providing direct oversight of Clinical Care Review (CCR) employees and overseeing day-to-day workflow within the CCR team.

Essential Functions:

• Provide direct oversight of CCR employees and oversee day-to-day workflow within the CCR team
• Ensure all direct reports are performing at minimum quality and productivity standards or better
• Understand complexities of health conditions and services
• Develop plan for management of workload after analyzing trends and act as advocate for CCR team
• Provide feedback, guidance, orientation, training and ongoing resources to CCRs and pre-authorization team
• Standardize activity and outcome reporting for department initiatives and programs including documentation required by the State and accrediting bodies
• Responsible for utilization review and discharge planning activities for CareSource members
• Monitor and ensure appropriate delivery of healthcare services in cost-effective manner
• Assist manager and director in development of process improvement activities and refining of processes that facilitate cost-effective utilization and appropriate levels of care
• Act as a liaison between Care Management, Claims, Enrollment, Customer Service and other areas as needed to assist in problem resolutions
• Perform audits of CCR team members to ensure compliance with CareSource policies, processes, regulatory requirements, NCQA utilization review guidelines and standards, and URAC review guidelines
• Provide input into CCR team evaluations and assist with development of team goals
• Design and present UM informational meetings as needed
• Responsible for attending state hearings as necessary
• Perform any other job duties as requested

Education and Experience:

• Graduate level degree as a mental health professional or Bachelor of Science degree in Nursing or equivalent years of relevant work experience is required
• One year of Utilization Management/Utilization Review experience required
• Minimum of five (5) years clinical experience preferred
• Certified Care Manager experience is preferred

Competencies, Knowledge and Skills:

• Basic computer skills
• Basic proficiency in Microsoft Word and Excel
• Communication skills
• Management skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field
• Critical listening and thinking skills
• Training/teaching skills
• Negotiation skills/experience
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Leadership experience and skills

Licensure and Certification:

• Current, unrestricted license as a Registered Nurse (RN) or a mental health professional (i.e. Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), etc.) is required. This listing may not include all acceptable licenses; please refer to your state licensing board for complete information on licensure requirements for your state or practice.
• Compact RN license or Multi-state Counselor/Social Worker licensure is preferred
• MCG Certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business