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Company Contact Info
- Houston, MO 65483
- Tomeka Newman
- Phone: 281-582-1802
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Clinical Review Manager (337-889)
HealthHelp • Houston, MO
Posted 2 months ago
- Enables team members to ensure consistent quality service to providers and members
- Manages staff with varying professional licenses and education levels
- Oversees and collaborates with other managerial staff in the department
- Give direction to and supervise others by offering approaches to be used and following up to ensure timely and quality execution against expectations
- Proposes, implements, and ensures adherence to approved process changes designed to meet business needs
- Facilitates an employee-oriented company culture that emphasizes quality, continuous improvement, key employee retention and development and high performance
- Delegates work to employees, tracks progress and provides constructive feedback in a timely manner
- Leads employees using a performance management and development process designed to provide an overall context and framework to encourage and enhance organizational value
- Leads employees to meet the organization's expectations for productivity, quality, and goal accomplishment
- Ensures that effective performance feedback is provided through employee recognition, rewards, and disciplinary action
- Establishes and maintains relevant controls and feedback systems to monitor the operation of the department as well as assigned program(s)
- Continuously tracks and monitors team and individual performance, in conjunction with Supervisory staff, and provides feedback and coaching to ensure performance goals are achieved
- Communicates with employees, other departments or staff regarding how to effectively research and resolve issues
- Communicates with employees and/or clients to ensure prompt and courteous attention to all questions regarding products and services
- Attends meetings in relation to program, project scope or as required
- Appropriately communicates organization information through department meetings, one-on-one meetings, appropriate email and regular interpersonal communication
- Provides regular operational updates to senior level managers
- Develops project scopes and objectives, involving all relevant stakeholders
- Develops a detailed project plan to track progress
- Oversees, reviews, or handles disciplinary actions in relation to staff, e.g., verbal warnings, records of discussion, and formal disciplinary documentation. Collaborates with human resources to ensure adherence to company policies.
- Responsible for knowing the intricacies of all benefit management programs including applicable regulatory compliance, accreditation standards, and client/health plan service level requirements for each program, line of business, and geographic region
- Assists with CMS ODAG and SARAG validation & clinical decision documentation audits upon request
- Assists with URAC and NCQA clinical file audits upon request
- Assists with service restoration efforts during emergencies
- Manages and ensures adherence to all company policies and procedures, including payor- specific turnaround times (TAT)
- Refers all complaints to Compliance Officer; works collaboratively with the Quality Department to investigate complaints and correct errors
- Participates in the Quality Management Program as appropriate
- Promotes business focus which demonstrates an understanding to the company's vision, mission and strategy
- Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics
Required Skills: OTHER DUTIES
- Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
- Graduate of an accredited school of nursing
- Current active unrestricted RN license in a state or territory of the United States required
- Minimum 3 years' experience in an acute care or managed care setting required
- Experience in team interactions and improvement methods/projects (e.g., coaching, quality and productivity)
- Ability to work in a fast-paced, evolving environment; on-call after hours work may be required
- Experience in conflict resolution
- Minimum of 2 years of progressively responsible supervisory experience in a managed care environment preferred
- Strong interpersonal skills at both individual and team level
- Excellent oral and written skills
- Proficient leadership and facilitation skills
- Ability to utilize critical thinking skills
- Excellent organizational skills
ENVIRONMENT AND PHYSICAL DEMANDS
- Business office environment or HIPAA compliant remote location
- Ability to use telephone for up to 8 hours unassisted
- Ability to sit for up to 8 hours unassisted
- Ability to enter data for up to 8 hours unassisted
- Ability to view PC screen for up to 8 hours
- Ability to prioritize in a multi-task environment