Lead, Care Coordinator

The Lead Utilization Management (UM) Coordinator provides operational leadership and oversight for the Utilization Management Coordinator team while supporting the coordination, processing, and administrative functions of the utilization review process. This role serves as a subject matter expert, ensuring timely, accurate, and compliant processing of authorization requests in accordance with established clinical guidelines, regulatory requirements, and organizational policies. The Lead UM Coordinator partners closely with UM nurses, physicians, leadership, providers, and other healthcare professionals to promote workflow efficiency, quality outcomes, and exceptional customer service.

Key Responsibilities

• Lead the daily operations and workflow of the UM Coordinator team to ensure timely processing of authorization requests.
• Serve as the primary resource and subject matter expert for UM Coordinators, providing guidance, coaching, and support on complex cases and operational issues.
• Assist leadership with onboarding, training, mentoring, and ongoing development of new and existing UM Coordinators.
• Monitor team productivity, work queues, turnaround times, and workload distribution to ensure compliance with regulatory and organizational standards.
• Receive, review, and process incoming requests for authorization of medical services.
• Coordinate with providers, members, and internal clinical staff to obtain required documentation for utilization reviews.
• Enter authorization requests, updates, and determinations into the utilization management system accurately and efficiently.
• Track and monitor pending authorizations to ensure timely processing and communication of decisions.
• Collaborate with UM nurses and physicians to facilitate medical necessity reviews and ensure adherence to clinical guidelines.
• Communicate authorization determinations (approvals, modifications, or denials) to providers and members within required regulatory timeframes.
• Perform quality reviews of authorization documentation and identify opportunities for process improvement.
• Assist leadership with audits, regulatory readiness, accreditation activities, and quality improvement initiatives.
• Escalate complex operational or system issues to management and recommend process improvements to enhance efficiency and service quality.
• Act as a liaison between internal departments, providers, health plans, and external vendors to resolve issues and improve collaboration.
• Assist with reporting, metrics tracking, and monitoring of key performance indicators (KPIs).
• Promote compliance with NCQA, CMS, state and federal regulations, health plan requirements, and organizational policies.
• Maintain strict adherence to HIPAA and confidentiality standards.

Education & Experience

• High School Diploma or equivalent required; Associate's degree in Healthcare Administration or a related field preferred.
• Minimum of 3–5 years of experience in a health plan or managed care environment.
• At least 2 years of Utilization Management, Prior Authorization, or Case Management support experience required.
• Previous experience serving as a team lead, trainer, mentor, or in an informal leadership role strongly preferred.
• Demonstrated ability to interpret health plan benefits and authorization guidelines.
• Bilingual (English/Spanish) required.
• Medical Assistant certification or other healthcare certification preferred.

Skills & Competencies

• Advanced knowledge of medical terminology, utilization management, prior authorization, and healthcare benefit processes.
• Strong understanding of regulatory and accreditation requirements, including NCQA, CMS, HIPAA, and health plan standards.
• Proficiency with Microsoft Office Suite and utilization management platforms (e.g., MCG, InterQual, or similar UM systems).
• Excellent leadership, coaching, mentoring, and team-building skills.
• Strong analytical, organizational, and problem-solving abilities.
• Outstanding written and verbal communication skills.
• Ability to prioritize multiple assignments and meet regulatory turnaround times in a fast-paced environment.
• Strong attention to detail and commitment to quality and compliance.
• Ability to work independently while supporting team performance and operational excellence.

Working Conditions

• The majority of work responsibilities are performed remotely.
• Position requires prolonged periods of sitting while working at a desk and using a computer.
• May require participation in virtual meetings, training sessions, audits, and operational support activities.
• Occasional schedule flexibility may be required to support business needs, workflow demands, or regulatory priorities.