Associate Manager, Clinical Review

About the role

We are seeking an Associate Manager, Clinical Claim Review to join our dynamic team. This role involves supervising a team of Coders, Clinical DRG Auditors, and Nurse Reviewers, overseeing their daily activities and managing their performance.

Responsibilities

• Oversee and manage the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality.
• Demonstrate effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; supporting those affected by change; monitoring transition and evaluating results.
• Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills to provide best-in-class practices to enhance efficiency, quality, and customer satisfaction.
• Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met.
• Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements.
• Meet with clients and providers to discuss complex cases, trend analysis, exit and/or settlement conferences.
• Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues, and coach and mentor staff to develop a high-performing team.
• Analyze reports and data and identify trends and resources that improve the delivery of clinical review services.
• Manage and evaluate individual/team performance and take appropriate action to meet and/or exceed performance standards.
• Perform other functions as assigned.

Requirements

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• Bachelor’s degree in business, healthcare administration, or related field preferred.
• 5+ years’ healthcare experience with increasing responsibility required.
• 3+ years’ utilization review or health care auditing experience required.
• 2+ years’ management or supervisory experience preferred.
• Demonstrates a thorough understanding of clinical criteria and clinical review judgment.

Qualifications

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC).
• Bachelor’s degree in business, healthcare administration, or related field preferred.
• 5+ years’ healthcare experience with increasing responsibility required.
• 3+ years’ utilization review or health care auditing experience required.
• 2+ years’ management or supervisory experience preferred.
• Demonstrates a thorough understanding of clinical criteria and clinical review judgment.

Skills

• Thorough understanding of clinical criteria and clinical review judgment.

Benefits

Gainwell offers competitive compensation, including a base pay range of $94,000.00 - $109,200.00 per year, with up to 20% travel. Other benefits include remote work within the US, a 401(k) employer match, comprehensive health benefits, and educational assistance. Gainwell is committed to fostering a diverse and inclusive workplace, and we offer various leadership and technical development academies to support career growth.

Pay

The pay range for this position is $94,000.00 - $109,200.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.

Schedule

Remote within the US. Up to 20% travel.