Healthonellc · Dalton, GAPrepare for this interview
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MISSION Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors. VALUES HealthOne is guided by a cultural framework that embodies our values and drives our decisions. Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent, and humble. We are continuously looking for ways to improve our PROCESS and how we get things done. HealthOne seeks individuals with integrity and heart to embody our values. Whether you're starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals. JOB PURPOSE The UM Nurse Team Lead ensures efficient, cost effective, and high quality delivery of utilization review service by supporting and training a staff of registered nurses; to oversee the management of medical cases worked by registered nurses; to oversee individual and overall results/outcomes of all cases within their scope of responsibilities; and to ensure customer satisfaction through the provision of cost effective and high quality utilization review service that meets their needs. ESSENTIAL JOB DUTIES - Serve as a clinical and operational team lead for Utilization Management nurses, providing day to day guidance, mentorship, and clinical support - Act as an escalation resource for complex utilization reviews, appeals, and provider/member issues requiring advanced clinical judgment - Trains and develops utilization review staff - Works with Utilization Management Manager to establish and ensure achievement of completion of prior authorization reviews, productivity, and quality goals - Initiate referrals to ensure appropriate coordination of care - Seek the advice of the Medical Director when appropriate, according to policy - Assists non-clinical staff in performance of administrative reviews - Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility - Maintains regular and predictable attendance - Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice - Works to encourage and promote Company culture throughout the organization - Other duties as may be assigned
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