About the role
The Utilization Management (UM) Nurse Supervisor is responsible for providing direct leadership and oversight to the UM nursing team. This role ensures team performance, accountability, and professional development by conducting regular 1:1s, managing performance reviews, and driving compliance with organizational, state, and federal requirements. The Supervisor balances hands-on operational responsibilities with leadership duties, serving as both a mentor and performance manager for frontline staff.
Salary: $75,000.00/Annually
JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES
The UM Nurse Team Lead’s responsibilities include but are not limited to:
* Provide day-to-day supervision of UM nurses, ensuring productivity, accuracy, and adherence to policies and processes. * Conduct regular 1:1s, coaching sessions, and performance evaluations to support staff growth and accountability. * Lead daily/weekly huddles, communicate priorities, and set expectations for performance and timeliness. * Serve as first point of escalation for staff questions, operational challenges, or case-related concerns. * Promote a culture of collaboration, accountability, and continuous improvement. * Monitor team productivity, timeliness, and quality of work through reporting and audits. * Take accountability for overall team performance, escalating issues as needed to the UM Clinical Manager. * Ensure compliance with all regulatory, contractual, and accreditation standards (CMS, NCQA, state-specific requirements). * Support audit preparation, quality initiatives, and corrective action plans as needed. * Oversee case assignment, queue management, and authorization workflows to ensure timely completion. * Perform authorization reviews as needed, utilizing federal/state mandates, plan benefit language, and medical necessity criteria (e.g., InterQual, CMS, health plan policies). * Review and process clinical and administrative appeals; coordinate with Medical Director when required. * Generate and review daily/weekly reporting on productivity and case timeliness. * Manage team calendars, including PTO, planned outages, and rotation schedules. * Participate in user acceptance testing (UAT), system/process improvements, and special projects. * Act as liaison between UM staff and UM leadership to ensure clear communication of priorities, policies, and workflow changes. * Collaborate with internal partners (e.g., Provider Relations, Quality) to resolve escalations and address utilization management issues. * Represent UM nursing team in internal meetings and external stakeholder interactions as directed. * Remote work environment with expectations for timely communication and responsiveness. * Must be able to handle confidential and sensitive information in compliance with company policies and regulations. * Flexibility to adapt to changing priorities, systems, and workflows in a fast-paced environment.
EDUCATION: Active, unrestricted Registered Nurse, Licensed Vocational Nurse, or Licensed Practical Nurse license
EXPERIENCE: * Minimum 3 years of nursing experience in acute, outpatient, or managed care setting. * Minimum 2 years of utilization management experience in a payer or managed care environment. * Strong understanding of utilization review, authorizations, and appeals processes. * Excellent verbal/written communication and organizational skills. * Experience with Medicare and Medicaid requirements. * Familiarity with DMEPOS authorization and appeals processes. * Knowledge of medical necessity criteria (InterQual, CMS, health plan policies). * Prior leadership, supervisory, or team lead experience in a UM setting.