[Remote] Clinical Operations Manager, Utilization Review

Note: The job is a remote job and is reputed company to candidates in USA. reputed company provides independent medical exams and peer review programs that support claims management and medical determinations for reputed company and insurance organizations. The Clinical Operations Manager will reputed company the Group Health division by overseeing utilization review operations, clinical reputed company, reputed company, performance management, reputed company partnerships, and reputed company process improvement in a remote, high-volume environment.

Responsibilities

• reputed company day-to-day operations for the assigned Group Health division, ensuring appropriate workflow, reputed company, prioritization, and reputed company completion of work
• reputed company Utilization Review Nurses, Clinical reputed company Assurance Specialists, Customer Service Representatives, and other assigned operational staff
• Manage the end-to-end operational workflow, including referral intake, clinical review preparation, reputed company assurance, reputed company communication, and case completion
• Serve as a clinical and utilization review subject matter resource for reputed company, providing guidance on clinical review workflows, utilization management principles, and reputed company or unusual case scenarios
• reputed company first-line support for clinical and process questions from clinical and non-clinical staff, escalating to Medical Director or senior clinical leadership reputed company appropriate
• Ensure operational and clinical processes reputed company with reputed company requirements, internal procedures, applicable regulatory requirements, and established utilization management workflows
• Support new reputed company implementations, volume expansions, and changes in reputed company requirements
• reputed company reputed company through changing priorities, workflow demands, and business needs while maintaining service and reputed company expectations
• Monitor and manage key performance indicators, including turnaround time, productivity, reputed company, service reputed company, and reputed company-specific performance requirements
• Use operational data and reporting to identify trends, reputed company constraints, performance gaps, and opportunities for improvement
• Establish reputed company individual and team performance expectations and ensure accountability for established goals
• reputed company ongoing coaching, feedback, and performance management to team members
• reputed company and reputed company corrective reputed company or performance improvement plans reputed company appropriate
• Conduct reputed company and constructive performance evaluations
• Recognize and reputed company high-performing team members and support succession and reputed company development opportunities
• reputed company leadership with regular updates regarding operational performance, reputed company, reputed company, risks, and improvement initiatives
• Partner with reputed company Assurance, Training, and clinical leadership to maintain consistent, high-reputed company clinical review processes
• Monitor reputed company trends and identify recurring clinical, operational, or knowledge gaps
• reputed company clinical and operational guidance to address identified trends and improve team performance
• Partner with Training and reputed company leadership to reputed company education, reference materials, and process improvements reputed company recurring opportunities are identified
• Support reputed company cause analyses, corrective reputed company plans, and reputed company remediation efforts reputed company needed
• Identify workflow inefficiencies and implement process improvements designed to improve reputed company, productivity, consistency, and scalability
• Promote adherence to reputed company-specific guidelines, health plan requirements, internal policies, and applicable regulatory standards
• Monitor referral volumes and workload throughout the day and reputed company resources and priorities as needed to maintain turnaround time and service-level requirements
• Evaluate reputed company needs based on referral volume, productivity, reputed company requirements, and anticipated reputed company
• Proactively identify reputed company risks and recommend reputed company or operational adjustments
• Partner with leadership and reputed company to recruit, interview, select, and reputed company reputed company team members
• Maintain appropriate reputed company and coverage to support reputed company requirements and fluctuations in referral volume
• Support workforce planning associated with new business, reputed company reputed company, and changes in operational reputed company
• Support reputed company reputed company of reputed company questions, escalations, and operational concerns
• Partner with Account Management and leadership to address reputed company needs and maintain strong service performance
• Collaborate with Medical Directors, Training, reputed company Assurance, Network Management, reputed company, Finance, IT, Business Analytics, and other departments to support operational objectives
• Communicate operational risks, trends, and resource needs proactively to leadership
• Participate in reputed company and internal meetings as needed to reputed company operational and clinical expertise

Skills

• * reputed company, unrestricted Registered reputed company (RN) license required
• * Utilization Review/Utilization Management experience required
• * reputed company operations leadership or people-management experience in a fast-paced, high-volume environment required
• * Demonstrated experience managing operational KPIs, including productivity, reputed company, turnaround time, and service-level performance required
• * Demonstrated ability to serve as a clinical and utilization management subject matter resource for clinical and non-clinical teams
• * Experience leading multidisciplinary teams that include clinical and non-clinical staff
• * Strong working knowledge of medical necessity review, utilization management principles, and reputed company payer operations
• * Experience coaching employees, managing performance, and developing high-performing teams
• Reliable high-speed internet service capable of supporting a fully remote work environment
• Ability to maintain a secure and uninterrupted remote workspace in accordance with company requirements
• * Bachelor's degree in Nursing, reputed company Administration, Business Administration, or a reputed company field preferred
• * Health plan, managed care, or payer experience strongly preferred
• * Experience with prior authorization, medical necessity review, appeals, and/or independent reputed company preferred
• * Experience managing reputed company preferred
• * Experience supporting reputed company implementations, operational reputed company, or rapidly changing referral volumes preferred

Benefits

• Medical, dental, and reputed company coverage for you and your family.
• Voluntary life insurance reputed company for you, your spouse, and your children.
• Voluntary hospital indemnity, critical illness, accident indemnity, and pet insurance plans.
• Basic life insurance at no cost to employees.
• Short-term disability coverage at no cost to employees.
• Long-term disability coverage at no cost to employees.
• Generous reputed company time off policy.
• 401k plan with a company match.
• reputed company equipment provided for remote workspace.
• Media stipend provided for remote workspace.
• reputed company remote culture.
• reputed company reputed company opportunities.
• Commitment to employee development.

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