Clinical Operations Manager

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

📋 Description

• Take ownership of the comprehensive clinical review process for medical certifications that support leave requests.

• Utilize clinical judgment to assess the sufficiency and consistency of documentation.

• Supervise daily clinical operations, including analysis of intermittent leaves and evaluations for extensions.

• Lead the medical certification team, focusing on hiring, coaching, and managing performance.

• Act as the clinical escalation point for contested certifications and work towards defensible resolutions.

• Facilitate cross-functional collaboration among Product, Legal, Compliance, and CX teams.

• Address operational challenges and eliminate bottlenecks impacting the efficiency of clinical reviews.

• Develop and enhance workflows to ensure consistent outcomes for reviewers.

• Create and revise Standard Operating Procedures (SOPs) and standards for documentation sufficiency.

• Oversee operational systems, reporting, and maintain documentation trails that are audit-ready.

• Analyze trends in certification reviews and implement continuous workflow enhancements.

• Ensure clinical consistency and compliance oversight.

• Manage licensing and credentialing processes for the clinical team.

• Support compliance initiatives and coordinate insurance and regulatory obligations.

• Collaborate with Compliance leadership on escalated and legally sensitive cases.

• Regularly align with departmental leaders on operational priorities and performance metrics.

• Evaluate operational performance and quality assurance results, conducting reviewer quality calibration.

• Establish performance standards and design onboarding and training programs.

• Plan operational enhancements and take charge of the roadmap for expanding the clinical operations function.

• Develop and lead ongoing educational initiatives for the Leave Specialist team.

⛳️ Requirements

• In-depth knowledge of FMLA, ADA, and state laws regarding paid leave/disability as they relate to clinical certification standards.

• A minimum of 3 years of experience in clinical review related to disability, leave-of-absence, or claims.

• RN license is strongly preferred; substantial experience in utilization review at an insurance company, TPA, or within a leave management setting may be considered as a substitute for licensure.

• Direct experience managing a care team with a focus on Short & Long-Term Disability, Family & Medical Leave Administration, and ADA Accommodations along with the Interactive Process.

• At least 3 years of experience in people management.

• Proven experience in designing or standardizing operational workflows, SOPs, or training programs.

• Strong ability to collaborate across functions with Compliance, Legal, Finance, CX, and Product teams.

• Comfortable in establishing a new function in a setting with ambiguity.

• Certification as a Case Manager (CCM) or a similar credential is a plus.

• Experience with URAC/NCQA accreditation is advantageous.

• Previous experience at a leave/disability carrier or TPA is beneficial.

• Must be legally authorized to work in the United States.

• Must be physically located and working within the United States.

🏝️ Benefits

• Full-time, exempt position.

• Remote work arrangement available.

• Equal opportunity employer committed to diversity.

• Supportive, collaborative team environment promoting diversity.

• Engage in mission-driven work that supports employees and People teams.

• Access to resources and scale from a venture-backed company.