Manager, Complex Clinical Review

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.

• →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.

• 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.