Utilization Review Specialist Team Lead

Company: Verida Inc
Location: Villa Rica
Posted on: February 13, 2026

Job Description:

Job Description Job Description Position Summary Onsite Villa Rica GA 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. Key Responsibilities - 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. Required Skills and Abilities - 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. Education and Experience - 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. Performance Measures - 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

Keywords: Verida Inc, Redan , Utilization Review Specialist Team Lead, Healthcare , Villa Rica, Georgia