Utilization Management Nurse Team Lead

Summary

Join Integra Partners as a Utilization Management (UM) Nurse Team Lead and play a key role in supporting the day-to-day operations of the UM team. This position requires strong communication, adaptability, and collaboration to drive operational excellence and regulatory compliance. You will provide leadership, guidance, and training to the team, ensuring compliance with standards and policies. Responsibilities include conducting inventory reporting, generating daily and weekly reports, managing team calendars, and ensuring case assignments. You will foster a supportive team environment and adapt to a fast-paced setting. The role also involves performing UM authorization reviews, processing appeals, and communicating with team members and external partners. This is a rewarding opportunity to contribute to a leading national durable medical equipment network administrator.

Requirements

• Active, unrestricted Registered Nurse, Licensed Vocational Nurse, or Licensed Practical Nurse license
• Minimum of 3 years of nursing in an acute or outpatient setting
• Minimum of 2 years of UM experience in a managed care, payor environment
• Verbal and written communication skills to convey information clearly and consistently

Responsibilities

• Support the day-to-day operations of the Utilization Management team
• Provide leadership, guidance, and training support to the team of nurses and UM Coordinators to ensure compliance with regulatory requirements and health plan policies
• Maintain compliance with all accrediting agency standards such as NCQA, CMS, and State agencies
• Conduct inventory reporting and notify leadership of any potential gaps or misses in timeliness, policy compliance, etc
• Compete daily reporting to ensure compliance with timeliness, CMS reporting, and health plan requirements
• Maintain real-time, proactive communication via Teams chat and ensure timely support for clinical and administrative questions
• Generate weekly reporting each week for productivity
• Maintain and manage team calendars, including planned outages and rotation schedules
• Ensure all nurse cases are assigned to a queue in UM/Manage Auths/Assign Auths
• Foster team-oriented, supportive environment with a focus on collaboration, accountability, and continuous learning
• Exhibit flexibility and resilience in a fast-paced, evolving environment and be able to adapt quickly to changes in workflows, tools and priorities
• Strong organizational skills, ability to adapt quickly to change, and desire to work in a fast-paced environment
• Team-oriented and self-motivated with a positive attitude
• Document processes and procedures related to utilization management
• Participate in special projects, reporting initiatives, User Acceptance Testing (UAT) testing, and system process improvements as needed
• Serve as the first line of support for staff questions and escalations. Should be comfortable navigating written guidance and using sound judgment when full step-by-step instructions aren’t available, with support available as needed
• Perform pre-service and post-service UM authorization reviews utilizing federal and state mandates, plan benefit language, and NCDs/LCDs as criteria for medical necessity reviews
• Process administrative and clinical appeals and refer as needed to the Medical Director
• Communicate effectively and professionally with team members, leadership and external partners
• Performs other duties as assigned

Preferred Qualifications

• Experience with Medicare and Medicaid (not required, but highly desirable)
• Experience with UM authorizations and appeals for DMEPOS (not required, but highly desirable)
• Experience with Medical Necessity Criteria including but not limited to InterQual, CMS guidelines, health plan medical policies, etc
• Experience writing denial letters is preferred

Benefits

• Competitive compensation and annual bonus program
• 401(k) retirement program with company match
• Company-paid life insurance
• Company-paid short term disability coverage (location restrictions may apply)
• Medical, Vision, and Dental benefits
• Paid Time Off (PTO)
• Paid Parental Leave
• Sick Time
• Paid company holidays and floating holidays
• Quarterly company-sponsored events
• Health and wellness programs
• Career development opportunities
• Remote Opportunities