Clinical Program Manager, Healthcare Review Services

About the Company - Managed Medical Review Organization is seeking a Claims Manager to oversee medical benefit determinations, formulary reviews, investigational treatment evaluations, and medical necessity reviews. In this role, you will lead a team ensuring compliance with regulatory guidelines and evidence-based coverage determinations. Your expertise in managed care, commercial insurance, Medicare, and Medicaid will be critical to optimizing review processes.

About the Role - Are you a strategic leader with expertise in healthcare utilization review, appeals, and grievances? Managed Medical Review Organization is seeking a Claims Manager to oversee medical benefit determinations, formulary reviews, investigational treatment evaluations, and medical necessity reviews.

Responsibilities

Operations Management:

• Responsible for the day-to-day operational oversight, staffing, workload assignment, and overall performance of HCR, specifically the clinical and administrative functions of the service line, ensuring efficient daily operations and compliance with corporate, accreditation, and client program performance standards and requirements.
• Provide guidance and direction to the HCR dedicated staff to assist with problem resolution, problem intervention, advice, and overall professional development.
• Monitor daily production and performance including turnaround timeframes, lead times, on-time performance, and first pass-yield.
• Develop and monitor daily operational activity reports for case processing, appropriate workload assignments, productivity measures, and problem identification.
• Inform the Director, Clinical Operations and Corporate Quality when further guidance is required, problems are identified, and/or to assist in facilitating the resolution of identified issues, as needed.
• Assist in staff hiring efforts, including participation in interviews, selection, and onboarding of new staff.
• Partners with the Vice President, Clinical Programs, and other members of the Executive Leadership Team as assigned, on new account on-boarding, service line and/or client program design, new client implementation, and ongoing client satisfaction measures.
• Participates in assigned client conference calls and/or meetings related to operational performance, Program implementation, operational updates and training, client needs, and/or new Program development. This includes onsite client meetings, as required.
• Assists the CQTC with leading the organization through successful IRO URAC reaccreditation cycles and validation reviews.

Quality Management:

• Assists the CQTC with the development and maintenance of an organizational Quality Management Program (QMP).
• Identifies, develops, and implements internal and external reporting needs.
• Assisting in the development and implementation of training modules specific to department and staff needs, client programs/policy, quality processes, and corporate policy.
• Works with department leadership and staff to identify departmental quality improvement and operational process improvement opportunities.

Qualifications

• Bachelor’s degree in nursing, health or management-related field
• Minimum two (2) years operational management experience
• Minimum two (2) years quality management experience
• Minimum five (5) years clinical experience
• Working knowledge of health care reviews (appeals, prior authorizations, etc.)
• Working knowledge of diagnostic coding (i.e., ICD-10)
• Working knowledge of CPT coding
• Critical thinking skills
• Good decision-making skills
• Detail-oriented
• Ability to work autonomously, as well as within a team structure
• Computer literate
• Good working knowledge of MS Word and Excel
• Good telephonic speaking skills
• Ability to multi-task
• Must be able to travel to onsite client meetings when attendance is required

Required Skills

• Extensive experience in claims management, utilization review, and appeals resolution
• Strong knowledge of medical necessity criteria, experimental treatment assessments, and formulary management
• Expertise in benefit determinations, policy interpretation, and regulatory compliance
• Ability to lead and mentor a high-performing team in medical claims adjudication
• Excellent communication, analytical, and decision-making skills

Preferred Skills

• Quality management experience preferred
• Prior health plan or IRO clinical experience preferred

Physical Demands

• Normal office environment. Stressful conditions may arise when workload becomes more demanding than normal. The physical requirements of the job are considered Sedentary Work per the U.S. Department of Labor, which is work involving the exertion of up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary Work involves sitting most of the time but may involve walking or standing for brief periods of time.

Pay range and compensation package - Pay range or salary or compensation