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Clinical Review Manager (337-889)

HealthHelp • Houston, MO

Posted 2 months ago

Job Snapshot

Full-Time
$77,060 - $78,060/Year
Healthcare - Health Services, Insurance
Health Care, Insurance

Job Description

MAJOR RESPONSIBILITIES

  • 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.

QUALIFICATIONS

  • 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
Job ID: 337-889
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