Manager, Clinical Operations

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

📋 Description

• Lead operations of the Benefit Determination Unit, ensuring that utilization management activities are timely, accurate, and compliant.

• Oversee performance metrics, resource utilization, complex case escalations, and operational initiatives to enhance efficiency and service excellence.

• Ensure adherence to regulatory, accreditation, contractual, and organizational standards.

• Supervise utilization management processes and quality assurance activities.

• Monitor performance metrics, conduct audits, and carry out operational reviews.

• Implement enhancements and corrective measures to improve quality, efficiency, and outcomes.

• Lead, mentor, and develop a high-performing team.

• Promote accountability, collaboration, and continuous improvement.

• Collaborate with appeals teams, health plans, providers, clients, and internal stakeholders.

• Support coordinated care, effective benefit determinations, and client satisfaction.

⛳️ Requirements

• Possess a current, active, and unrestricted license issued by a state or territory in the United States to practice independently, with a legal scope allowing independent assessments; eligible professions include Clinical Social Worker, Marriage and Family Therapist, Professional Counselor, Clinical Psychologist, or Registered Nurse.

• Hold a Bachelor's degree in Nursing, Social Work, Counseling, Psychology, or a related healthcare field.

• Have over 5 years of clinical experience in utilization management, care management, behavioral health, healthcare operations, or a related clinical setting.

• Possess at least 3 years of formal clinical supervisory experience or demonstrated leadership capability.

• Strong understanding of utilization management principles, medical necessity criteria, benefit determination processes, appeals, and clinical review functions.

• Familiarity with state and federal regulatory requirements, accreditation standards (e.g., NCQA, URAC), and health plan contractual obligations.

• Experience in analyzing performance metrics, managing operational workflows, and leading quality improvement initiatives.

• Excellent communication, stakeholder management, problem-solving, and decision-making abilities.

• Proficient with clinical documentation systems, care management platforms, and Microsoft Office applications.

• Certification in Case Management (CCM) must be obtained within 3 years if overseeing care management teams.

• Willingness to travel 10% of the time.

• Must pass background checks and screenings upon hire and throughout employment, including criminal records, sanctions/exclusions, education and employment verification, drug screening, and E-Verify.

• Professional demeanor with an ability to collaborate across various levels of professionals and staff.

• Strong attention to detail.

• Capability to manage multiple tasks in a fast-paced, dynamic environment.

• Ability to take a lead role in ensuring objectives are achieved.

• Access to a quiet workspace with minimal background noise for calls.

• High-speed internet connection must be established prior to starting, with minimum download speed of 20 Mbps, upload speed of 5 Mbps, and maximum latency of 100 milliseconds.

🏝️ Benefits

• Annual performance-based, discretionary incentive.

• Comprehensive medical, dental, and vision coverage.

• 401(k) plan with a competitive employer match.

• Company-paid life and disability insurance.

• Paid parental leave and well-being incentives.

• Generous paid time off, including volunteer time.

• Flexible spending accounts for healthcare and dependent care.

• Opportunities for professional development and tuition reimbursement.

• Remote work flexibility (dependent on role).

• Company-provided equipment.

• Opportunities for meaningful personal and professional growth.