Manager, Clinical Escalations

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

📋 Description

• Create and execute a structured escalation framework, which encompasses intake processes, triage criteria, severity classifications, tracking systems, and reporting schedules.

• Shift the escalation responsibilities from the Client Success team to a specialized program.

• Act as the main point of accountability for client and provider escalations received.

• Classify, allocate, and resolve escalations based on established workflows.

• Supervise open escalations and ensure completion and documentation of follow-up actions.

• Ensure internal teams are held accountable for prompt resolution.

• Monitor and enforce regulatory and contractual response-time obligations.

• Identify risks and implement corrective measures when turnaround times are jeopardized.

• Handle sensitive escalations from executive-level clients or providers.

• Inform Cohere leadership about escalation risks.

• Oversee, mentor, and assist one direct report, the Escalations Analyst.

• Generate dashboards and reports on escalation metrics such as volume, resolution rates, compliance with turnaround times, root causes, and trends.

• Collaborate with Client Success, Clinical Operations, Compliance, Product, Clinical Content, and other teams to tackle systemic challenges.

• Develop and maintain standard operating procedures (SOPs), escalation playbooks, and communication templates.

⛳️ Requirements

• A Bachelor's degree in healthcare.

• Active clinical licensure in the state of residence (RN, PT/OT/SLP considered).

• Over 3 years of experience in utilization management operations.

• Experience in communications with external clients, providers, and/or members.

• Understanding of healthcare regulations and accreditation (CMS, Medicaid, JCAHO).

• Proficiency in spreadsheet functions, including data analysis and quantitative conclusions.

• Experience in driving process enhancements.

• Capability to work independently and navigate uncertainties to establish a cross-functional program.

• Strong problem-solving abilities with a focus on customer satisfaction.

• A passion for enhancing the U.S. healthcare system and ensuring every patient receives optimal care.

• Familiarity with ticketing or project management software (e.g., CRM, JIRA, Monday.com) is advantageous.

• Proven success in implementing new programs is a plus.

• Experience in people leadership is considered an advantage.

• Background in managing escalations within a multi-client or multi-health-plan setting is a plus.

• Understanding of root cause analysis (RCA) methodologies and corrective action plan (CAP) development is a plus.

🏝️ 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.

• Flexible spending and health savings accounts.

• Flex Time Off plus company-recognized holidays.

• Up to 14 weeks of paid parental leave.

• Pet insurance available.

• Bonus included in the overall benefits package.