Team Lead, Clinical Care Review

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