[Hiring] Nurse Team Lead @WNS Global Services

Role Description

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.

Qualifications

• 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).

Requirements

• 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.

Benefits

• 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