Manager, Complex Clinical Review

The company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

The ideal candidate leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Manager will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.

What You’ll Do

• Oversee the Complex Clinical Bill Review team, managing production expectations, SLA’s, client communication, and team performance.

• Analyze and track internal business requirements and processes through document and workflow analysis.

• Continuously evaluate the functionality across multiple programs to ensure efficient and accurate reviews.

• Perform requirements gathering to problem solve for any process-related issues that require attention from development.

• Manage team member’s current assignments and collaborate across teams/departments for timeliness to ensure all internal and external SLAs are met.

• Oversee the development and application of clinical review concepts, such as experimental and investigational, pharmacy utilization, level of care, medical appropriateness, and medical policy adherence.

• Delegate tasks and responsibilities to team members and oversee specials projects that involve the team.

• Coordinate system enhancements for the clinical review team, including JIRA ticket creation, UAT testing, and production employment.

• Monitor team’s performance, tracking and trending the metrics of the team to identify opportunities for growth and efficiency.

• Identify the needs of team members, paying special attention to issues that require attention from IT.

• Develop and coordinate training materials, quality assurance process, and dispute response workflows for the team.

• Support internal operations to keep the team abreast of any organizational or client policy changes.

• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.

• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.

• Coordinate and contribute to the dispute resolution process for all clinical appeals received.

• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.

• Act as liaison between the Operations team and Client Success team in order to quickly address and resolve any client related issues.

• Effectively ensures adherence to medical review guidelines and training requirements of staff.

• Provides support as needed to ensure auditors are equipped with tools and resources required to perform clinical audits.

• Complete and conduct performance reviews for assigned staff.

• Conduct team meetings with direct reports on a regular basis.

• Organize and coordinate the onboarding of all new team members.

• Other duties as assigned.

What You Bring

Required Skills/Qualifications

• Current, unrestricted nursing license in good standing is required - certified coding certification is a plus.

• 3+ years relevant supervisory or leadership experience in similar business environment, preferred. Experience managing remote staff is a plus.

• 3+ years’ experience performing clinical audits of itemized bills.

• 3+ years’ diverse nursing experience providing direct care in an inpatient or outpatient setting.

• Proven experience with healthcare industry software products and process development.

• Experience managing multiple projects in a team environment.

• Possess a broad and comprehensive understanding of audit standards, policies and regulations, applies a broad and comprehensive knowledge in areas including, medical chart reviews.

• Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking.

• Consulted often by others for advice and opinions and recognized as a leadership role model.

• Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management.

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• Ability to prioritize and multitask.

• Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style.

• Proven experience in managing high performing dynamic teams.

• Ability to work in a diverse and fast paced environment.

• Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes

• Strong working knowledge of Windows office systems including full Microsoft Suite and Teams.

• Advanced software skills in Microsoft Office (Excel).

• Experience with various forms of software and experience engaging development teams.

What We Offer

• Work from anywhere in the US! The company is digital-first.

• Full Medical/Dental/Vision for employees & their families

• Flexible and trusting environment where you’ll feel empowered to do your best work

• Unlimited FTO

• Competitive salary, equity, 401(k) including employer match

Pay range : $115,000 - $130,000 USD.  The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.

Equal Employment Opportunity at the company

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. The company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at:  [link for members]