Team Lead, Clinical Care Review

CareSource; Dayton (OH); Hybrid; USD 72,000 - 116,000; Full time

Job summary

CareSource in Dayton, Ohio is seeking a Team Lead, Clinical Care Review to oversee CCR staff and manage day-to-day workflow.

The role ensures quality and productivity standards, mentors CCRs and the pre-authorization team, and coordinates with Care Management, Claims, Enrollment and Customer Service to resolve issues.

Qualified candidates hold an RN or mental health license, UM/UR experience, and 5+ years of clinical practice; leadership experience is preferred.

Qualifications

• Graduate level degree in mental health or BSN in nursing or equivalent.
• One year of Utilization Management/Utilization Review experience required.
• Minimum of five years clinical experience preferred.
• Certified Care Manager experience preferred.

Responsibilities

• Provide direct oversight of CCR employees and oversee day-to-day workflow within the CCR team
• Ensure all direct reports are performing at minimum quality and productivity standards
• Understand complexities of health conditions and services
• Develop plan for workload management after analyzing trends and advocate for CCR
• Provide feedback, guidance, orientation, training and ongoing resources to CCRs and pre-authorization team
• Standardize activity and outcome reporting for department initiatives and programs
• Responsible for utilization review and discharge planning activities for CareSource members
• Monitor and ensure appropriate delivery of healthcare services in cost-effective manner
• Assist in process improvement and refining of processes that facilitate cost-effective utilization
• Act as liaison between Care Management, Claims, Enrollment, Customer Service and other areas
• Perform audits of CCR team members to ensure policy/regulatory compliance
• Provide input into CCR team evaluations and assist with team goals
• Design and present UM informational meetings as needed
• Attend state hearings as necessary

Skills

Basic computer skills

Microsoft Word

Microsoft Excel

Communication skills

Management skills

Supervisory skills

Team leadership

Attention to detail

Time management

Customer service oriented

Problem solving

Education

Graduate degree in mental health or related field

RN licensure or mental health professional licensure

BSN or equivalent experience

Tools

Office software

Job description

Job Summary

The Team Lead, Clinical Care Review is responsible for providing direct oversight of Clinical Care Review (CCR) employees and overseeing day-to-day workflow within the CCR team.

Essential Functions

• Provide direct oversight of CCR employees and oversee day-to-day workflow within the CCR team
• Ensure all direct reports are performing at minimum quality and productivity standards or better
• Understand complexities of health conditions and services
• Develop plan for management of workload after analyzing trends and act as advocate for CCR team
• Provide feedback, guidance, orientation, training and ongoing resources to CCRs and pre-authorization team
• Standardize activity and outcome reporting for department initiatives and programs including documentation required by the State and accrediting bodies
• Responsible for utilization review and discharge planning activities for CareSource members
• Monitor and ensure appropriate delivery of healthcare services in cost-effective manner
• Assist manager and director in development of process improvement activities and refining of processes that facilitate cost-effective utilization and appropriate levels of care
• Act as a liaison between Care Management, Claims, Enrollment, Customer Service and other areas as needed to assist in problem resolutions
• Perform audits of CCR team members to ensure compliance with CareSource policies, processes, regulatory requirements, NCQA utilization review guidelines and standards, and URAC review guidelines
• Provide input into CCR team evaluations and assist with development of team goals
• Design and present UM informational meetings as needed
• Responsible for attending state hearings as necessary
• Perform any other job duties as requested

Education and Experience

• Graduate level degree as a mental health professional or Bachelor of Science degree in Nursing or equivalent years of relevant work experience is required
• One year of Utilization Management/Utilization Review experience required
• Minimum of five (5) years clinical experience preferred
• Certified Care Manager experience is preferred

Competencies, Knowledge and Skills

• Basic computer skills
• Basic proficiency in Microsoft Word and Excel
• Communication skills
• Management skills
• Prior supervisory skills
• Ability to work independently and within a team environment
• Attention to detail
• Familiarity of the healthcare field
• Critical listening and thinking skills
• Training/teaching skills
• Negotiation skills/experience
• Proper grammar usage
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Leadership experience and skills

Licensure and Certification

• Current, unrestricted license as a Registered Nurse (RN) or a mental health professional (i.e. Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), etc.) is required.
• This listing may not include all acceptable licenses; please refer to your state licensing board for complete information on licensure requirements for your state or practice.
• Compact RN license or Multi-state Counselor/Social Worker licensure is preferred MCG Certification preferred.

Working Conditions

General office environment; may be required to sit or stand for extended periods of time.

Compensation

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level.

• Compensation Range: $72,200.00 - $115,500.00
• In addition to base compensation, you may qualify for a bonus tied to company and individual performance.
• We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary): Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture
• Cultivate Partnerships
• Develop Self and Others
• Drive Execution
• Influence Others
• Pursue Personal Excellence
• Understand the Business

Equal Opportunity and Diversity

CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

#LI-JM1 Brand=CareSource

CareSource Mission

The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.

Job Description Disclaimer

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time.