Manager, Complex Clinical Review

Machinify

3d • $115,000 - $130,000 • Remote

About The Position

The ideal candidate leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Manager will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.

Requirements

• Current, unrestricted nursing license in good standing is required - certified coding certification is a plus.
• 3+ years relevant supervisory or leadership experience in similar business environment, preferred. Experience managing remote staff is a plus.
• 3+ years’ experience performing clinical audits of itemized bills.
• 3+ years’ diverse nursing experience providing direct care in an inpatient or outpatient setting.
• Proven experience with healthcare industry software products and process development.
• Experience managing multiple projects in a team environment.
• Possess a broad and comprehensive understanding of audit standards, policies and regulations, applies a broad and comprehensive knowledge in areas including, medical chart reviews.
• Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking.
• Consulted often by others for advice and opinions and recognized as a leadership role model.
• Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management.
• Ability to prioritize and multitask.
• Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style.
• Proven experience in managing high performing dynamic teams.
• Ability to work in a diverse and fast paced environment.
• Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes
• Strong working knowledge of Windows office systems including full Microsoft Suite and Teams.
• Advanced software skills in Microsoft Office (Excel).
• Experience with various forms of software and experience engaging development teams.

Nice To Haves

• certified coding certification is a plus.
• Experience managing remote staff is a plus.

Responsibilities

• Oversee the Complex Clinical Bill Review team, managing production expectations, SLA’s, client communication, and team performance.
• Analyze and track internal business requirements and processes through document and workflow analysis.
• Continuously evaluate the functionality across multiple programs to ensure efficient and accurate reviews.
• Perform requirements gathering to problem solve for any process-related issues that require attention from development.
• Manage team member’s current assignments and collaborate across teams/departments for timeliness to ensure all internal and external SLAs are met.
• Oversee the development and application of clinical review concepts, such as experimental and investigational, pharmacy utilization, level of care, medical appropriateness, and medical policy adherence.
• Delegate tasks and responsibilities to team members and oversee specials projects that involve the team.
• Coordinate system enhancements for the clinical review team, including JIRA ticket creation, UAT testing, and production employment.
• Monitor team’s performance, tracking and trending the metrics of the team to identify opportunities for growth and efficiency.
• Identify the needs of team members, paying special attention to issues that require attention from IT.
• Develop and coordinate training materials, quality assurance process, and dispute response workflows for the team.
• Support internal operations to keep the team abreast of any organizational or client policy changes.
• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.
• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.
• Coordinate and contribute to the dispute resolution process for all clinical appeals received.
• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.
• Act as liaison between the Operations team and Client Success team in order to quickly address and resolve any client related issues.
• Effectively ensures adherence to medical review guidelines and training requirements of staff.
• Provides support as needed to ensure auditors are equipped with tools and resources required to perform clinical audits.
• Complete and conduct performance reviews for assigned staff.
• Conduct team meetings with direct reports on a regular basis.
• Organize and coordinate the onboarding of all new team members.
• Other duties as assigned.

Benefits

• Full Medical/Dental/Vision for employees & their families
• Flexible and trusting environment where you’ll feel empowered to do your best work
• Unlimited FTO
• Competitive salary, equity, 401(k) including employer match

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed