Full-Time Nurse - Clinical Review

• Supervises a team of clinical staff.
• Conducts performance appraisals and documents reviews.
• Handles disciplinary actions.
• Ensures quality service to clients, providers, and members.
• Tracks and monitors performance metrics.
• Conducts team and staff meetings.
• Improves clinical assessment process.
• Oversees staff work assignments.
• Partners with Workforce Planning for resource allocation.
• Addresses escalated issues.
• Coordinates with Programs and Client Services for process enhancements.
• Identifies issues and suggests improvements.
• Acts as liaison for Client Service issues.
• Develops a rewards system.
• Motivates team members.
• Facilitates a healthy work environment.
• Supports teamwork and respect.
• Manages phone metrics using telephony, ACD, and workforce systems.
• Maintains knowledge of benefit management programs and compliance.
• Collaborates with HR on company policies.
• Refers complaints to compliance.
• Assists with service restoration during emergencies.
• Answers questions regarding Plan benefits.
• Promotes business focus.
• Adheres to HIPAA, state, and federal regulations.
• Adheres to URAC & NCQA standards.

Requirements:

• Current active unrestricted RN or LVN/LPN license.
• Minimum 3 years’ experience in UM/QM or managed care.
• Minimum 2 years of supervisory experience in managed care preferred.
• Excellent interpersonal and presentation skills.
• Proficient leadership and facilitation skills.
• Ability to work in a fast-paced environment.
• Excellent organizational skills.
• Self-starter with critical thinking skills.
• Experience in team interactions and improvement projects.
• Knowledge of Microsoft Office.

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