Associate Manager, Clinical Claim Review

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee daily activities related to prepay, post-pay, prior authorization, and medical record review within a multidisciplinary team.

• Direct, assign tasks, and ensure that productivity and quality metrics are met.

• Analyze production processes and workflows to enhance efficiency and quality.

• Effectively communicate and manage organizational changes.

• Supervise hiring, retention, performance management, training, and educational initiatives.

• Provide leadership, mentorship, and coaching to Coders, Clinical DRG Auditors, and Nurse Reviewers.

• Monitor aging inventory, workload, task assignments, productivity levels, quality standards, service level agreements, contract deliverables, and timelines.

• Assess productivity, utilization, efficiency, finding rates, savings, appeal overturn rates, and completed reviews.

• Engage with clients and providers on complex cases, trend analysis, exit conferences, and settlement discussions.

• Act as a subject matter expert for new tools, automation, product development, and clinical readiness.

• Address escalated issues and analyze reports and data to identify trends and resource needs.

• Manage and assess individual and team performance, taking necessary actions.

• Perform other assigned duties as needed.

⛳️ Requirements

• Active, unrestricted RN license from the United States and in the primary home residency, along with an active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC), or CPC, CCS, or CPMA certification is required.

• A Bachelor's degree in business, healthcare administration, or a related field is preferred.

• A minimum of 5+ years of healthcare experience with increasing levels of responsibility is required.

• Preferred experience includes 3+ years in utilization review or healthcare auditing.

• Preferably, candidates should have at least 2+ years of management or supervisory experience.

• A comprehensive understanding of clinical criteria and clinical review judgment is necessary.

• Must have the ability to work remotely within the United States.

• Willingness to travel up to 20% is required.

🏝️ Benefits

• Flexible hours and work arrangements.

• Emphasis on work-life balance.

• Opportunities for continuous learning and career development.

• Generous and flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance is available.

• Participation in leadership and technical development academies.

• Up to 20% travel opportunities.