Clinical Integrity Manager

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

📋 Description

• Conduct clinical evaluations of products, workflows, and programs to ensure alignment with evidence-based practices, regulatory standards, and client requirements.

• Develop and enhance clinical specifications, user narratives, and acceptance criteria for Utilization Management workflows, clinical decision support systems, and AI-driven functionalities.

• Uphold clinical integrity during sprint planning and design meetings involving Product and Engineering teams.

• Execute hands-on User Acceptance Testing (UAT), create testing scripts and scenarios, document issues, and monitor readiness for product releases and client deployments.

• Review client commitments and Service Level Agreements (SLAs) against product functionalities, identify discrepancies, and lead corrective actions.

• Create and sustain governance documentation, Standard Operating Procedures (SOPs), playbooks, and training resources.

• Collaborate with Clinical Operations, Product, Engineering, Client Success, Compliance, Legal, and Clinical Strategy teams.

• Provide clinical evaluations, responses to Requests for Proposals/Information (RFP/RFI), and feasibility assessments for potential clients.

⛳️ Requirements

• Registered Nurse (RN), Physical Therapist (PT), Occupational Therapist (OT), or Speech-Language Pathologist (SLP) with a current, unrestricted clinical license.

• Bachelor's degree in Nursing, Therapy, Healthcare Administration, or a related discipline.

• Over 5 years of progressive experience in Utilization Management, Clinical Operations, or health plan functions.

• Minimum of 2 years in a leadership or supervisory role.

• Comprehensive understanding of Medicare Advantage, Medicaid, Commercial, and Marketplace Utilization Management.

• Familiarity with CMS regulations, NCQA accreditation processes, and delegation oversight.

• Proven experience collaborating with Product and Technology teams to develop clinical workflows and digital solutions.

• Proficient in hands-on execution, including documentation writing, workflow testing, process tool development, and detail management.

• Excellent communication and stakeholder influence abilities.

• A Master's degree, experience with AI-enabled clinical workflows, familiarity with InterQual® or MCG®, Lean/Six Sigma/Agile/PM certification, or previous UAT/QA experience are advantageous.

🏝️ Benefits

• Fully remote position with approximately 10% travel required.

• Comprehensive medical, dental, vision, life, and disability insurance, along with an Employee Assistance Program.

• 401K retirement plan with company matching contributions.

• Flexible spending account and health savings account options.

• Flexible Time Off plus company holidays.

• Up to 14 weeks of paid parental leave.

• Pet insurance available.

• Bonus included as part of the overall benefits package.