Associate Manager, Clinical Claim Review

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

📋 Description

• Oversee the daily operations of prepay, post-pay, prior authorization, and medical record review tasks performed by Coders, Clinical DRG Auditors, and Nurse Reviewers.

• Lead the team by assigning tasks and ensuring that productivity and quality targets are met.

• Evaluate production and workflow processes to enhance efficiency and quality.

• Communicate modifications, foster commitment, navigate resistance, support impacted staff, and supervise transitions.

• Manage hiring, talent retention, performance evaluation, training coordination, and provide leadership and mentorship.

• Track aging inventory, workloads, task assignments, productivity, and quality in accordance with service-level agreements, contract obligations, and deadlines.

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

• Engage with clients and providers concerning 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 while coaching and mentoring staff.

• Analyze reports and data to identify trends and resources that enhance clinical review service delivery.

• Manage and assess both individual and team performance, taking actions to meet or exceed established standards.

• Perform additional assigned duties.

⛳️ Requirements

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

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

• A minimum of 5 years of healthcare experience with progressively increasing responsibilities is required.

• At least 3 years of experience in utilization review or healthcare auditing is preferred.

• A minimum of 2 years of management or supervisory experience is preferred.

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

🏝️ Benefits

• Flexible hours.

• Work-life balance.

• Continuous learning and career development opportunities.

• Generous and flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

• Up to 20% travel.