Job Description
MAJOR RESPONSIBILITIES
• Balances between case review production and team lead duties based on business needs and staffing levels
• Conducts case reviews as assigned
o Maintains a minimum target of 3.5 cases per hour (CPH) when processing cases during productivity hours
• Monitors staff work assignments and adjusts the nurse assignment tool based on staffing levels, proficiency, types of request, and amount of cases received; frontline staff pull their assignments directly from the tool
o Ensures case-specific turnaround time (TAT) related to client service level agreements and regulatory compliance requirements are met for their specified program(s)
o Communicate expectations, assignments and responsibilities clearly and professionally
o Acts as a liaison between frontline staff and upper management
• Assists with daily physician reviewer case coordination and notifications
• Monitor team performance to ensure proper processes are being followed and report on areas of opportunity to Supervisor
o Functions as a subject matter expert for assigned program modalities/procedures
o Disseminates information, as appropriate, to staff members
o Evaluates and monitors case work by team members to identify any gaps or outliers
o Ensures that staff members are successful by providing support to new and existing staff as a valuable resource
o Listen to team members' feedback and resolve any issues or conflicts
o Enables team members to ensure consistent quality service to provider and members
o Collaborates with other departments, as assigned, to ensure proper protocol is being followed and obtain clarifications, as needed
• Conducts selected reviews/auditing of cases within the Clinical Review department to identify training opportunities based on appropriateness of the review determinations
o Coordinates with Nursing Management and Clinical Review Training Department to identify educational and refresher training needs for individual nurses or across the Clinical Review Department
o Conducts periodic one-on-ones with Clinical Review Nurses to offer tips on process improvement and clinical review
o Identify potential improvements in clinical review process and criteria
o Participate in HH Nurse Education group email to provide responses to nurses' questions regarding specific cases and clinical review processes
STANDARD DEPARTMENTAL RESPONSIBILITIES
• Provide secondary Nursing Management coverage for assisting staff during Manager or Supervisor unavailability due to meetings, PTO, etc.
• Handles escalated inbound calls or requests from providers
• Assists with inventory management, including monitoring case volumes and queues to support timely assignment and completion
• Actively participates or conducts meetings as directed by Supervisor or Manager
• Develop, implement, and utilize a multifaceted rewards system that makes team members excited to show up to work every day and do their best
• Use empowerment, trust and other strategies as appropriate to develop and motivate team members
• Facilitate a healthy and motivating work environment and atmosphere
• Utilizes knowledge of AVAYA, ADP Workforcenow. and related systems to manage daily phone metrics
• Capable of collaborating with client personnel to resolve customers' concerns
• Responsible for knowing the intricacies of all benefit management programs including applicable regulatory compliance, accreditation standards, and client/health plan service level requirements for each program, line of business, and geographic region
• Refers all complaints to Compliance Officer, as appropriate; works collaboratively with the Quality Department to investigate complaints and correct errors
• Evaluate and report HIPAA breaches according to policy
• Collaborates with human resources to ensure adherence to company policies
• Promotes business focus which demonstrates an understanding of the company's vision, mission, and strategy
• Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others
• Adheres to all HIPAA, state and federal regulations pertaining to the clinical programs
• Adheres to both URAC & NCQA standards pertinent to their job description
• Performs other related duties and projects as assigned
• Please note this job description is not designed to cover or contain a comprehensive list of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Qualifications
QUALIFICATIONS
• Graduate of an accredited school of nursing
• Current active, unrestricted RN or LVN/LPN license in a state or territory of the United States required
• Minimum of 2 years of Utilization Management (UM) experience required; additional experience in QM, acute care, or managed care setting preferred
• Excellent interpersonal, written and presentation skills, including the ability to handle interactions with facility personnel, providers, members and various internal departments in a professional manner
• Demonstrates leadership and motivational skills
• Ability to work in a fast-paced, evolving environment, on-call after hours work may be required
• Ability to utilize critical thinking skills
• Experience in team interactions and improvement methods/projects (e.g., coaching quality and productivity)
• Understanding of HealthHelp's products and services
• Strong interpersonal and communication skills
• Knowledge of Microsoft Office and programs including Outlook, PowerPoint, Excel, Word and Visio
ENVIRONMENT AND PHYSICAL DEMANDS
• Business office environment or HIPAA compliant remote location
• Ability to use telephone for up to 8 hours unassisted
• Ability to sit for up to 8 hours unassisted
• Ability to enter data for up to 8 hours unassisted
• Ability to view 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.
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
How to Apply
Please submit your application, including a resume and optional cover letter, through our careers page or email to [redacted].
