Team Lead, Care Specialist UM

Team Lead, Care Specialist UM Remote

Summary of Position :

The Team Lead, Care Specialist UM is responsible for supporting utilization management processes, supervising non-clinical staff, and ensuring compliance with organizational, regulatory, and legal requirements. This role includes staff oversight, caseload management, and serving as a key contributor to projects, initiatives, and operational improvements.

Key Responsibilities

• Support non-clinical functions required for successful utilization management.
• Ensure work is completed within appropriate timeframes and in compliance with regulatory and organizational standards.
• Supervise 5 8+ non-clinical staff, including assignment planning, workload balance, and performance oversight.
• Manage a personal caseload 50% of the time.
• Represent the team and supervisor in projects, testing sessions, and organizational initiatives.
• Conduct performance reviews, mentoring, and coaching of staff.
• Participate in staff hiring and performance improvement processes.
• Provide direction to the team on schedules, priorities, and issue resolution.
• Serve as a subject matter expert on processes, systems, and delegated functions.
• Research and resolve authorization discrepancies and claims issues.
• Communicate authorization decisions and benefit information to members and providers.
• Collaborate across departments to resolve issues and ensure process efficiency.
• Monitor quality, cost, and efficiency trends and recommend improvements.
• Provide case review, documentation oversight, and preauthorization support as needed.
• Lead and develop staff, ensuring adherence to organizational and departmental goals.
• Perform additional related duties as assigned.

Qualifications:

Education, Training, Licenses, Certifications

• Bachelor's degree required (additional experience may substitute).

Experience, Knowledge, Skills, Abilities

• 3 5+ years of managed care experience, preferably in utilization management or prior authorization.
• Experience in non-clinical UM or care management operations.
• Familiarity with discharge planning, care transitions, and quality measures.
• Strong knowledge of medical terminology, ICD, and CPT coding.
• Experience working with community health and social service agencies.
• Strong communication, problem-solving, and organizational skills.
• Ability to work independently, set priorities, and manage a flexible schedule.
• Computer literacy with Windows and automated systems.
• Bilingual (English/Spanish) preferred.
• Customer service and data entry expertise; competency in UM functions (acute care, home care, prior authorization, etc.).
• Must be available to work weekends and holidays as needed.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.