Clinical Operations Specialist

Mass General Brigham•Somerville, MA

8d•$99,466 - $141,804•Remote

About The Position

Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The Clinical Operations Specialist oversees daily operational workflows within the Physician Review Unit to ensure medical review decisions are timely, compliant, and consistent. This role acts as a critical bridge between clinical decision-making and administrative execution, driving operational efficiency by managing high-volume workflows that support the Medical Director team's strategic goals. The Clinical Operations Specialist is responsible for spearheading process improvement initiatives, fostering cross-departmental collaboration, and managing the administrative frameworks essential for Utilization Management, appeals, and quality compliance. Working closely with Medical Directors and cross-functional partners in Network Management, Provider Relations, Claims, and Customer Service, the Specialist resolves complex and escalated cases while strictly monitoring regulatory standards, Turnaround Time (TAT), and compliance requirements. Troubleshoots the end-to-end UM process and coordinates changes with the training area.

Requirements

Bachelor's Degree required
At least 2-3 years of experience working in a health plan environment required, but preferably in Utilization Management
Strong understanding of utilization management workflows, including physician reviews, prior authorization processes, appeals, peer reviews, and out-of-network (OON) reviews required
Strong analytical and critical thinking skills, with the ability to interpret clinical data and guidelines.
Excellent communication and interpersonal skills, adept at communicating with professionals from many different backgrounds and disciplines.
Proficiency in healthcare software systems and the Microsoft Office suite.
Detail-oriented and organized, with strong problem-solving skills.
Committed to patient-centered care and continuous quality improvement.
Demonstrated ability to work effectively with Medical Directors, physicians, and senior clinical leaders.

Nice To Haves

Clinical background with patient care experience preferred
Process improvement experience preferred

Responsibilities

Manages daily case volume in the physician queues and facilitates case assignment as needed, in accordance with TAT and regulatory requirements.
Collaborates with data analytics and quality to monitor Medical Director review volumes and quality metrics, including inter-rater reliability.
Works with the Medical Directors to collect quality concerns regarding cases sent to the unit.
Identify bottlenecks in the clinical review lifecycle and implement "lean" strategies to reduce turnaround times and administrative functions.
Optimizes physician unit operations by leading workflow design, ensuring regulatory compliance, and embedding changes through standardized documentation and training.
Attends and facilitates cross-functional area case discussion with the Deputy Chief Medical Officer, Senior Medical Director, and other clinical leadership.
Responsible for keeping schedules of MDs and assuring coverage, and coordinating the vacation process.
Collaborates cross-functionally with Utilization Management, Network Management, Provider Relations, and Customer Service to resolve complex cases and escalate provider or contract issues.
Performs other duties as assigned
Complies with all policies and standards