Associate Manager, Clinical Review

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

📋 Description

• Accountable for overseeing the daily prepay, post-pay, prior authorization, and medical record review operations of a diverse team comprising Coders, Clinical DRG Auditors, and Nurse Reviewers.

• Directs and manages the team's daily activities by leading, assigning tasks, ensuring productivity and quality benchmarks are met, and analyzing production and workflow processes to enhance efficiency and quality.

• Regularly exhibits effective change management by promptly and efficiently communicating changes; fostering commitment and addressing resistance; supporting those impacted by changes; monitoring transitions, and assessing outcomes.

• Responsible for staff oversight and recruitment, retaining top talent, managing performance, coordinating training and education, and providing leadership and mentorship to enhance skills for best-in-class practices aimed at improving efficiency, quality, and customer satisfaction.

• Track aging inventory, workload, assignments, productivity, and quality to guarantee that service level agreements, contract obligations, and timelines are met.

• Assess and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rates, and reviews completed by staff to identify avenues for process enhancements.

• Engage with clients and providers to address complex cases, conduct trend analysis, and facilitate exit and/or settlement discussions.

• Act as a Subject Matter Expert to evaluate new tools, automation, product development, and clinical readiness; serve as a resource for resolving escalated issues, and mentor staff to cultivate a high-performing team.

• Examine reports and data to identify trends and resources that enhance the provision of clinical review services.

• Manage and assess individual and team performance, taking necessary actions to achieve or surpass performance standards.

• Execute additional functions as assigned.

⛳️ Requirements

• Active, unrestricted RN license from the United States and in the primary home residency.

• Active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).

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

• Over 5 years of healthcare experience with increasing responsibility is required.

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

• Preferred management or supervisory experience of 2+ years.

• Demonstrates a comprehensive understanding of clinical criteria and clinical review judgment.

🏝️ Benefits

• Up to 20% travel.