Manager, Clinical Cost Containment

Healthcare Management Administrators•Bellevue, WA

2d•$110,000 - $140,000•Remote

About The Position

The Clinical Cost Containment Manager is responsible for the operational development and execution of value programs within Care Management. This program is designed to promote health and financial savings for members and clients with a focus on preventing inappropriate or incorrect claim payments prior to adjudication. This dynamic role understands performance trends, monitors for variances and can present findings to other leaders and partners. The leader oversees prepayment clinical review, medical necessity validation, and coding accuracy initiatives to ensure claims are compliant with benefit plans, coding and clinical guidelines, and regulatory requirements while supporting cost containment for self-funded employer clients. You will develop deep subject-matter-expertise and understanding of our customers and our TPA market so you can be a trend-setter, continuously improving processes and effective delivery to maximize the value of HMA’s cost containment services. You will lead a diverse team of coders and nurses to achieve the program objectives. This leader partners closely with Utilization Management, Analytics, Finance, Compliance and Client Success while growing capabilities for promoting value at HMA.

Requirements

Bachelor's degree or equivalent required in related field
3-5+ years of experience in leadership within the healthcare, insurance, revenue cycle, payment integrity, or cost-containment industries
Strong understanding of healthcare claims coding (CPT, HCPCS, ICD‑10) and its impact on reimbursement and claims adjudication.
Excellent technical and organizational skills with a successful track record of accountability for end-to-end delivery of operational initiatives
Strong data analysis skills, with the ability to make data-driven business recommendations quickly
Demonstrated experience building program growth strategies with medium to long term program roadmaps
Communicate well and influence direct reports, colleagues and executives
Expert problem solving and organizational abilities
Experience collaborating and communicating with different stakeholders
Ability to lead, develop, motivate, and hold others accountable
Highly developed relationship-building skills
Experience with MS Office Suite including advanced PowerPoint skills

Responsibilities

Lead the execution, optimization, and evolution of clinical cost containment initiatives, including: Coding Policy Review and coding accuracy validation
Post‑service medical necessity review
Fraud, Waste, and Abuse (FWA) identification and escalation
Translate organizational and client objectives into clear program goals, success metrics, and operating plans, with accountability for revenue, savings, and operational performance targets.
Ensure clinical review programs align with plan documents, clinical guidelines, regulatory requirements, and service‑level expectations for self‑funded employer groups.
Oversee timely and accurate turnaround of clinical reviews to support claims adjudication workflows and minimize operational disruption.
Partner with Claims Operations to balance payment accuracy, turnaround time, and member/provider experience.
Identify operational risks, bottlenecks, and opportunities for automation or workflow enhancement across cost containment processes.
Evaluate program outcomes and cost avoidance strategies, ensuring rigorous, defensible tracking of savings, recoveries, and revenue opportunities.
Perform and oversee data analysis to monitor program health, identify trends, and proactively adjust strategy based on performance insights.
Maintain high‑quality data and documentation to support internal reporting, client deliverables, stop‑loss partners, and finance reconciliation.
Promote a culture of data‑driven decision making across the team and among cross‑functional partners.
Lead performance and quality improvement initiatives, including root‑cause analysis and corrective action planning, to ensure program effectiveness and scalability.
Ensure processes are compliant with regulatory standards, audit requirements, and contractual obligations.
Continuously assess industry trends, coding changes, and evolving clinical standards to inform future program enhancements.
Lead, mentor, and develop a multidisciplinary team of clinical payment integrity coders, nurses, and analysts.
Set clear performance expectations, provide coaching and feedback, and build a high‑performing, engaged team.
Provide strategic guidance that supports professional growth, operational excellence, and strong collaboration across disciplines.
Serve as a key collaborative partner with: Employer Groups and Account Managers Stop‑Loss Carriers Finance and Analytics teams Claims and Care Management leadership
Participate in client‑facing discussions related to program performance, savings outcomes, and future roadmap planning.
Communicate complex clinical and financial concepts with clarity, confidence, and professionalism to members, providers, internal stakeholders, and external partners.