• Utilization Management Pre-Service Review Nurse Team Lead - Chicago

    Job Location US-IL-Chicago
    Job ID
    Utilization Management
    Business Line
    CMC Corporate
  • Overview

    Who we are:

    Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.


    We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.


    Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.


    A Day in the Life of a Utilization Management Pre-Service Review Nurse:

    This position is responsible for specific functions within the Utilization Management Department including, orientation and training of new utilization management staff, monitor and report progress of new member training, provide staff training for new and updated policies and procedures, perform user testing for new MCS applications/functionality, monitor and optimize staff caseloads, oversee small projects and manage half the case load as expected of a full time case manager.  This position also provides first line clinical direction to the utilization management staff and refers to Manager of Clinical Services when necessary.


    • Develop 60 day orientation/training schedule for new clinical utilization management staff
    • Monitor staff progress weekly and update training orientation outline accordingly
    • Provide at least weekly written progress reports to manager and updated training outline
    • Discuss issues or potential opportunities for staff improvement with manager
    • Identifies expected outcomes of the nurse reviewer orientation program and ongoing education programs
    • Ensure training manual is updated regularly as revisions are made to processes, job aides, policies, procedures, etc.
    • Implement new/revised processes among clinical utilization management staff
    • Provide written materials as needed for training purposes
    • Oversee workloads by monitoring the work queues of each staff member to ensure timeliness in decision making, and discharge planning activities are performed in accordance with HPM policies and procedures
    • Discuss variances that may be identified in team member case load/performance with manager; such as: untimely decision, insufficient documentation, lack of discharge planning, no evidence of appropriate referrals
    • In conjunction with manager, act as resource for criteria and benefit interpretation including the correct and consistent application of the clinical criteria on the appropriate topics, consistent application of procedural practices established by MHP and accurate and consistent utilization of medical director services
    • Supply ongoing training and education to the staff through one-on-one and classroom settings regarding InterQual, URAC, MDCH and other necessary job-related skills
    • Oversee the Discharge Planning activities of clinical staff and timely referral of appropriate referrals to the case management staff; including but not limited to, the collection of key member demographic information, identification of member baseline condition, activities of daily living, and physician discharge plan
    • Develop a plan of action, obtaining the necessary equipment and supplies, negotiating prices, developing case contract, obtaining timely clinical updates, and monitoring the length of stay
    • Oversee activities conducted by clinical nurse reviewers and their timely, accurate application of decision criteria
    • Monitor denial correspondence for consistency and accuracy with decisions, member language (when appropriate), and pertinent information. Monitor all correspondence for compliance Inform manager of variances with URAC, MDCH, and HIPAA guidelines
    • Provide front line direction to clinical utilization management staff and consult with manager as appropriate for input
    • Ensure team members accurately record pertinent information for weekly prolonged length of stay report
    • Work in collaboration with Manager and administrative assistant to plan orientation schedule for new staff members
    • Once new staff member is assigned clinical cases, team leader will review cases weekly and provide immediate feedback to new staff member
    • Provide for ongoing clinical training and education of all staff based on needs assessments done with each staff member to determine areas where more training is required
    • Provide for training for any MCS updates that would affect the case management staff
    • Work in collaboration with Manager to develop job aides for the clinical utilization management staff
    • Acts as a liaison with other MHP departments in relation to case management issues
    • Works collaboratively with Manager to perform monthly quality audits on clinical utilization management staff members
    • Assists Manager in the creation of the agenda for the weekly clinical utilization team meetings
    • Conducts weekly team meetings in the absence of the Manager
    • Consistently demonstrates compliance with HIPAA regulations, professional conduct and ethical practice
    • Assists with special projects or departmental process improvement efforts, as needed
    • Manage half the case load as a full time nurse reviewer


    What you can bring to Meridian:

    • Current license (without restriction) to practice as a Licensed Practical Nurse or Registered Nurse in the designated State is required
    • A minimum of 1 year case management experience
    • Knowledge of managed care
    • Knowledge of case management processes including tools and techniques for identification, stratification and management of high-risk members
    • Must possess working knowledge of MDCH regulations

    What Meridian can offer you:

    • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
    • Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
    • Meridian offers 401k matching that is above the national average.
    • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
    • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.


    Equal Opportunity Employer



    Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.
    Share on your newsfeed

    Connect With Us!

    Not ready to apply? Connect with us for general consideration.