Utilization Management Nurse Team Lead

The Utilization Management (UM) Nurse Team Lead plays a key role in supporting the day-to-day operations of the UM team and serves as a liaison between frontline staff and leadership. This position requires strong communication skills, adaptability, and a collaborative approach to drive operational excellence and ensure regulatory compliance.

Salary: $67,000/annually

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES

The UM Nurse Team Lead’s responsibilities include but are not limited to:

• 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

EDUCATION : Active, unrestricted Registered Nurse, Licensed Vocational Nurse, or Licensed Practical Nurse license

EXPERIENCE:

• 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
• 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
• Verbal and written communication skills to convey information clearly and consistently

Benefits Offered

• 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

We are actively seeking new colleagues in: Arizona, Colorado, Connecticut, Florida, Georgia, Idaho, Illinois, Kentucky, Massachusetts, Michigan, North Carolina, New Jersey, New York, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Vermont, and Washington.

Our Story

Founded in 2005, Integra Partners is a leading national durable medical equipment, prosthetic, and orthotic supplies (DMEPOS) network administrator. Our mission is to improve the quality of life for the communities we serve by reimagining access to in-home healthcare. We connect Payers, Providers, and Members through innovative technology and streamlined workflows affording Members access to top local Providers and culturally competent care. By focusing on transparency, accountability, and adaptability, we help deliver better health outcomes and more efficient management of complex healthcare benefits. Integra Partners is a wholly owned subsidiary of Point32Health.

With a location in Michigan plus a remote workforce across the United States, Integra has a culture focused on collaboration, teamwork, and our values: One Team, Drive Results, Push the Boundaries, Value Others, and Build Community. We’re looking for energetic, talented, and dedicated individuals to join our team. See what opportunities we have available; there may be a role for you to engage in a challenging yet rewarding career in healthcare. We look forward to learning more about you.

Integra Partners is an equal opportunity employer. We are committed to providing reasonable accommodations and will work with you to meet your needs. If you are a person with a disability and require assistance during the application process, please don’t hesitate to reach out. We celebrate our inclusive work environment and welcome members of all backgrounds and perspectives.