Manager, Complex Clinical Review

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

📋 Description

• Supervise the Complex Clinical Bill Review team, overseeing production expectations, SLAs, client communication, and team performance.

• Analyze and monitor internal business requirements and processes through comprehensive document and workflow analysis.

• Assess functionality across various programs to ensure efficient and accurate reviews.

• Conduct requirements gathering to address process-related issues that necessitate development support.

• Manage team assignments and collaborate across teams and departments to fulfill internal and external SLAs.

• Oversee the development and application of clinical review concepts, encompassing experimental and investigational treatments, pharmacy utilization, level of care, medical appropriateness, and adherence to medical policy.

• Delegate responsibilities and supervise special projects.

• Coordinate system improvements, including JIRA ticket creation, UAT testing, and production deployment.

• Monitor team performance metrics to identify opportunities for growth and efficiency.

• Identify team member needs, including issues that require IT intervention.

• Develop and organize training materials, quality assurance processes, and dispute response workflows.

• Support internal operations related to organizational or client policy changes.

• Stay updated on medical practices, technology, regulations, legislation, and business trends.

• Conduct audit quality assurance reviews as necessary.

• Coordinate and contribute to the resolution of clinical appeals disputes.

• Suggest cost-saving measures and opportunities for improving outcomes.

• Act as a liaison between Operations and Client Success to address client concerns.

• Ensure compliance with medical review guidelines and staff training requirements.

• Provide auditors with necessary tools and resources.

• Complete performance reviews for assigned staff members.

• Hold regular team meetings with direct reports.

• Organize onboarding processes for new team members.

• Perform additional duties as assigned.

⛳️ Requirements

• A current, unrestricted nursing license in good standing is mandatory.

• Certification in coding is an advantage.

• A minimum of 3 years of relevant supervisory or leadership experience in a similar business environment is preferred.

• Experience managing remote teams is a plus.

• At least 3 years of experience conducting clinical audits of itemized bills.

• A minimum of 3 years of diverse nursing experience providing direct care in either an inpatient or outpatient setting.

• Proven experience with healthcare industry software products and process development.

• Experience in managing multiple projects within a team setting.

• A broad and comprehensive understanding of audit standards, policies, and regulations, including medical chart reviews.

• Strong project management and interpersonal skills.

• Ability to prioritize and manage multiple tasks effectively.

• Excellent communication skills, both verbal and written.

• Demonstrated experience managing high-performing dynamic teams.

• Ability to thrive in a diverse and fast-paced environment.

• Strong problem-solving, analytical, interpersonal skills, teamwork, people management, and process management capabilities.

• Proficient knowledge of Windows office systems, including the full Microsoft Suite and Teams.

• Advanced software skills in Microsoft Office, especially Excel.

• Experience with various software applications and collaboration with development teams.

🏝️ Benefits

• Work from anywhere in the United States.

• Comprehensive Medical/Dental/Vision coverage for employees and their families.

• A flexible and trusting work environment.

• Unlimited Flexible Time Off (FTO).

• Competitive salary.

• Equity opportunities.

• 401(k) plan with employer matching.