Nurse Team Lead - Clin Rev

About this role

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 teamwor

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