Clinical Operations Manager – Utilization Review

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

📋 Description

• Oversee the daily operations for Dane Street’s Group Health division.

• Manage workflow, staffing, prioritization, and ensure the timely completion of utilization and independent clinical reviews.

• Supervise Utilization Review Nurses, Clinical Quality Assurance Specialists, Customer Service Representatives, and other operational personnel.

• Oversee referral intake, preparation for clinical reviews, quality assurance, client communication, and case closure.

• Offer clinical and utilization review support and first-line assistance for complex procedural inquiries.

• Ensure adherence to client specifications, internal protocols, regulatory standards, and utilization management processes.

• Assist with new client implementations, volume increases, and modifications to client expectations.

• Track turnaround times, productivity, quality, service levels, and client-specific KPIs.

• Analyze operational metrics to uncover trends, capacity limitations, performance deficiencies, and areas for enhancement.

• Establish performance standards, mentor staff, conduct evaluations, and manage corrective actions or performance improvement initiatives.

• Acknowledge high achievers and facilitate succession planning and professional growth.

• Collaborate with Quality Assurance, Training, and clinical leadership on quality enhancements, educational initiatives, root cause analysis, and corrective measures.

• Identify inefficiencies in workflow and execute scalable process improvements.

• Monitor referral volumes and adjust resources and priorities to ensure service levels are maintained.

• Assess staffing requirements and suggest operational modifications.

• Collaborate with leadership and Human Resources to recruit, interview, select, and onboard new team members.

• Assist in workforce planning for new business opportunities, client expansion, and changes in operational scope.

• Address client inquiries, escalations, and operational issues.

• Work in conjunction with Medical Directors, Account Management, Training, Quality Assurance, Network Management, Human Resources, Finance, IT, and Business Analytics.

• Report operational risks, trends, resource needs, staffing forecasts, and recommendations to leadership.

• Engage in client and internal meetings as an operational and clinical authority.

⛳️ Requirements

• Active, unrestricted Registered Nurse (RN) license is mandatory.

• A Bachelor’s degree in Nursing, Healthcare Administration, Business Administration, or a related field is preferred.

• Experience in Utilization Review/Utilization Management is required.

• Proven leadership experience in healthcare operations or people management in a fast-paced, high-volume setting is essential.

• Familiarity with managing operational KPIs, including productivity, quality, turnaround time, and service-level performance is crucial.

• Ability to act as a clinical and utilization management subject matter expert for both clinical and non-clinical teams.

• Experience in leading multidisciplinary teams comprising clinical and non-clinical staff is necessary.

• Understanding of medical necessity reviews, utilization management principles, and healthcare payer operations is important.

• Proven track record of coaching employees, managing their performance, and cultivating high-performing teams.

• Experience in health plans, managed care, or payer systems is strongly preferred.

• Background in prior authorization, medical necessity reviews, appeals, and/or independent review services is preferred.

• Experience in managing remote teams is a plus.

• Familiarity with supporting client implementations, operational growth, or rapidly changing referral volumes is preferred.

• Access to reliable high-speed internet service capable of accommodating a fully remote work environment is required.

• Capability to maintain a secure and uninterrupted remote workspace in compliance with company policies is essential.

• Ability to perform tasks that involve prolonged sitting and computer work.

🏝️ Benefits

• Medical, dental, and vision insurance coverage for employees and their families.

• Optional life insurance plans available for employees, spouses, and children.

• Coverage options for hospital indemnity, critical illness, accident indemnity, and pet insurance.

• Basic life insurance provided at no cost.

• Short-term disability coverage offered at no cost.

• Long-term disability coverage provided at no cost.

• Generous paid time off policy.

• 401k plan with company matching contributions.

• Apple equipment provided for remote work setups.

• Media stipend for remote workspace expenses.

• A collaborative remote work culture.

• Opportunities for professional development and growth.

• Commitment to employee advancement and development.