Lead Utilization Review - RN
$79,040–$91,520 year
RemoteUnited States
Job Summary
Establish daily direction for the Utilization Management team by setting priorities, reinforcing expectations, and building a culture of clinical quality and accountability. Coach reviewers on consistent application of medical-necessity criteria, medical policies, and benefit language while providing real-time answers during complex interpretations. Monitor workflow health by tracking intake volume, aging cases, and turnaround risks, then flag barriers to the manager with specific recommendations. Audit reviewer documentation for completeness and audit readiness, coaching staff on sharper clinical rationale and regulatory timeliness. Build reviewer capability through shadowing plans, job aids, and competency check-ins to identify and resolve training gaps. Resolve cross-team barriers by partnering with providers, facilities, Case Management, Appeals, and Provider Relations to keep determinations moving. Maintain HIPAA compliance and model ethical decision-making while driving training completion for yourself and your team.
Required Qualifications
- Active RN license
- Experience in utilization management, clinical review, or case management
- Background applying medical-necessity criteria and benefit plan interpretation in a healthcare payer or clinical review setting
- Proficiency with UM platforms and standard office/productivity tools
- Working knowledge of medical terminology and coding concepts (ICD-10, CPT, HCPCS) sufficient to support accurate UM documentation
- Familiarity with remote collaboration tools for team visibility and responsiveness
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