Utilization Review Specialist Team Lead

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Full Time Villa Rica, GA, US

2 days ago Requisition

Lead and manage the Utilization Review team that reviews member transportation requests outside contractual mileage guidelines and non‑covered Medicaid services/locations. Ensure timely, accurate, compliant decisions; oversee subscription/standing‑order program operations; handle escalations, quality assurance, reporting, and staff development.

• Supervise daily operations of the Utilization Review (UR) team: assign work, monitor throughput, ensure quality and adherence to policy and contractual guidelines.
• Review and approve/deny complex or escalated transportation requests outside mileage guidelines and requests to non‑covered services/locations when delegated.
• Oversee review and enrollment of facilities into the Subscription/Standing Order Transportation Program for NEMT.
• Supervise issuance of Member Warning Letters as appropriate.
• Ensure timely completion and accuracy of departmental reporting: daily denial letters, member no‑show letters, monthly denial summary; review and submit the Monthly Denial Summary Report to clients/regions.
• Develop, implement and maintain standard operating procedures, decision criteria, and quality controls for UR processes.
• Train, coach, and evaluate UR Specialists; conduct performance reviews, corrective action, and career development planning.
• Monitor key performance indicators (turnaround time, accuracy/appeals rate, denial justification, report timeliness) and implement process improvements to meet contractual agreements.
• Serve as primary escalation point for internal departments, external healthcare providers, and client inquiries; represent UR in cross‑functional meetings.
• Maintain confidentiality and ensure compliance with Medicaid/Medicare rules, state regulations, contractual obligations, and HIPAA.
• Participate in audits and support remediation activities; prepare executive summaries and trend analyses for leadership.

• Strong knowledge of Medicaid and Medicare rules and transportation/non‑emergency medical transport (NEMT) processes; familiarity with dialysis and nursing home placement a plus.
• Proven supervisory experience with ability to manage, mentor, and motivate staff in a high‑volume, high‑stress environment.
• Excellent written and verbal communication, conflict resolution, and interpersonal skills for sensitive situations.
• Strong analytical and sound judgment skills; ability to make consistent, well‑documented decisions.
• Proficient with Microsoft Word and Excel; familiarity with utilization review preferred.
• Highly organized, self‑directed, flexible, and able to manage competing priorities across internal and external stakeholders.

• High school diploma or equivalent required;
  Associate’s degree or higher in healthcare administration, nursing, social work, or related field preferred.
• Minimum 3–5 years’ experience in healthcare utilization review, customer service in healthcare, NEMT, or related operations, with at least 1–2 years in supervisory or lead role.
• Experience working with Medicaid programs, community resources, dialysis providers, and long‑term care placement preferred.

• Timeliness: percentage of requests processed within contractual turnaround times.
• Accuracy: upheld decisions on appeal.
• Reporting: on‑time and error‑free submission of daily and monthly reports to clients.
• Team metrics: staff productivity, attendance, and training completion.