Utilization Review RN Team Lead

About the Role

The Utilization Review (UR) Nurse Team Lead provides clinical and operational leadership to support the UR nursing team in completing accurate, timely, and compliant medical necessity reviews. This role offers day-to-day oversight of workflow management, quality assurance, staff development, and onboarding activities. The Team Lead ensures adherence to established clinical criteria, regulatory requirements, and client-specific expectations, while collaborating with the Director of Utilization Management and serving as a subject matter expert in utilization review processes.

Responsibilities

• Support UR nurses in conducting hospital admission and continued stay reviews to determine medical necessity and appropriate patient status (inpatient, observation, outpatient) using approved clinical criteria and guidelines, such as InterQual® and/or MCG®.
• Oversee daily team workflow to ensure UR nurses complete assigned reviews accurately and in order of established priorities.
• Audit UR nurse reviews for accuracy, completeness, and compliance with client-specific processes and requirements.
• Provide ongoing feedback, coaching, and performance guidance to the UR nurse team.
• Support training and onboarding of new UR nurses.
• Support client onboarding and assist with client communication and follow-up.
• Perform other duties as assigned by the Director of Utilization Management.

Requirements

• Graduate of an accredited school of nursing.
• Bachelor’s of Science in Nursing (BSN): preferred.
• Current, unrestricted Registered Nurse (RN) license.
• Minimum five (5) years of acute care nursing experience in a hospital setting.
• Minimum three (3) years of recent hospital-based or health plan acute utilization review experience.
• Advanced experience with acute admission reviews and continued stay reviews.
• Certified Case Manager (CCM), Accredited Case Manager (ACM), Certified Managed Care Nurse (CMCN), or Case Management Board Certification (CMGT-BC): preferred.

Skills

• Proficient in multiple Electronic Health Records and case management systems.
• Strong communication skills, both verbal and written.
• Demonstrated ability to coach and mentor others.
• Ability to thrive in a fast-paced environment and adapt to frequent changing business needs.
• Ability to work independently with minimal supervision.
• Advanced level of experience with InterQual and/or MCG within the last two years.
• Experience in Microsoft Suite including Office and basic Excel.

Schedule

• Scheduled shift may be 8-, 10-, or 12-hour shifts based on operational needs and mutual scheduling agreements.
• Team Leads are not assigned a regular weekend work schedule or holidays; however, they are expected to be available on an on-call basis to support critical staffing and operational needs as necessary.
• Work schedules are published one month in advance.
• Requests for vacation, time off, or schedule accommodations must be submitted at least thirty (30) days before the schedule is finalized (e.g., requests for the August schedule must be submitted by June 30).

Working Conditions

• Conditions typically associated with an office environment.
• Regularly required to speak or hear.
• Frequently required to sit, stand, or walk.
• Moderate to prolonged reading, typing, and computer work.
• Ability to perform tasks involving physical activity that may include lifting up to 25 pounds.
• Subject to exposure to all environmental hazards associated with healthcare and office work.