Nurse Team Lead - Clin Rev

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 t