Case Management Team Lead

What you will do

• Oversees daily staffing, scheduling, and workflow to ensure appropriate coverage and continuity of utilization and case management services.
• Delivers side-by-side support, mentorship, and skill development to team members to promote clinical excellence, consistency, and adherence to utilization and care coordination standards.
• Ensures team members perform duties in accordance with professional standards, hospital policies, payer requirements, and regulatory guidelines.
• Guides staff in interpreting medical necessity criteria, evaluating appropriateness of services, and obtaining timely authorizations from managed and commercial payers.
• Serves as an escalation resource for complex clinical, authorization, discharge, or payer-related issues and supports appropriate resolution prior to leadership involvement.
• Identifies trends, strengths, and improvement opportunities in clinical practice and workflow and escalates themes to departmental leadership.
• Applies critical thinking and problem-solving skills to address workflow challenges, clinical barriers, and payer issues in real time.
• Promotes collaboration among physicians, nursing, social work, finance, and ancillary departments to support safe, timely patient care transitions.
• Arranges staff coverage as needed and provides direct coverage when necessary to meet patient care demands.
• Supports onboarding, orientation, and ongoing education of new employees, students, and assigned personnel.

Education Qualifications

BS Nursing required or Associates degree in Nursing with a nursing certification.

Experience Qualifications

Three (3) years clinical experience with one (1) year of experience in Utilization Management, Case Management or two years in Emergency Management. Ability to read, write and speak English clearly and distinctly. Knowledge of Microsoft Office including Word, Excel, and PowerPoint required.

Skills and Abilities

• Comprehensive knowledge of case management and utilization management, including care progression, discharge planning, authorization processes, and medical necessity management across Medicare, Medicaid, managed care, and commercial payer types.
• In-depth experience applying InterQual or similar nationally recognized medical necessity criteria to evaluate appropriateness of admissions, continued stays, services, and level-of-care determinations.
• Ability to apply advanced clinical expertise and utilization management principles to evaluate appropriateness of services, resolve barriers to care, and support desired patient, quality, and organizational outcomes.
• Knowledge of federal, state, local, and payer regulatory requirements related to utilization review, reimbursement, discharge planning, care coordination, and compliance standards.
• Ability to mentor, coach, and support team members through side-by-side guidance, skill development, and performance feedback.
• Ability to coordinate daily staffing, scheduling, and workflow; manage competing priorities; monitor workload distribution; and maintain departmental efficiency.
• Strong communication skills with the ability to collaborate effectively with physicians, interdisciplinary teams, patients, families, payers, and leadership.
• Proficiency in Microsoft applications, including Outlook, Teams, Word, and Excel.
• Ability to utilize electronic medical records, utilization management systems, and reporting tools.