Clinical Operations Lead

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

📋 Description

• Act as the main clinical consultant for designated hospital and health system clients.

• Establish and nurture robust relationships with client leadership, which includes Case Management Directors, Revenue Cycle Leaders, Physician Advisors, and C-suite executives.

• Perform evaluations of utilization review processes and pinpoint areas for operational enhancement.

• Offer strategic insights to enhance authorization procedures, minimize denials, and maximize reimbursement.

• Lead client meetings, deliver findings, and relay project updates to stakeholders.

• Aid in the implementation of process enhancements and track performance metrics.

• Review inpatient and outpatient utilization management processes to ensure compliance and efficiency.

• Examine denial trends, payer behaviors, and utilization patterns.

• Work alongside physician advisors and operational teams to enhance medical necessity documentation and improve appeal success rates.

• Provide counsel on CMS, Medicare, Medicaid, and commercial payer stipulations.

• Assist clients with managing length-of-stay, authorization processes, and strategies to prevent denials.

• Create and implement best practices in utilization management and revenue integrity.

• Educate client teams on regulatory updates, payer expectations, and industry best practices.

• Develop training materials, workflows, and standard operating procedures.

• Mentor and support internal consultants and clinical team members.

• Act as a subject matter expert during client engagements and business development initiatives.

⛳️ Requirements

• At least 7 years of experience in Utilization Review, Case Management, or Revenue Cycle.

• A minimum of 3 years of direct experience with hospital systems in a consulting or client-facing role.

• In-depth understanding of: Hospital revenue cycle operations, Utilization management, Denial management, Medical necessity criteria, Payer regulations, and reimbursement methodologies.

• Proven experience in presenting to executive leadership and facilitating client meetings.

• Strong familiarity with Medicare, Medicaid, and commercial payer requirements.

• Experience with electronic medical records, preferably Epic.

• Exceptional presentation and communication skills.

• Ability to establish credibility and influence stakeholders at all levels.

• Strong analytical and problem-solving skills.

• Self-motivated with the capability to manage multiple client engagements concurrently.

• Proficient in Microsoft Office applications, especially Excel and PowerPoint.

🏝️ Benefits

• Up to 25% travel, as required by client engagements.