Associate Manager, Clinical Claim Review
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Job Description
Associate Manager leading clinical claim review operations for Gainwell Technologies, a healthcare solutions provider. Supervising multidisciplinary teams, quality metrics, audits, and process improvements.
Responsibilities:
- Supervise day-to-day prepay, post-pay, prior authorization, and medical record review activities of a multidisciplinary team
- Lead, assign work, and ensure productivity and quality metrics are achieved
- Analyze production and workflows to increase efficiency and quality
- Communicate and manage organizational changes effectively
- Oversee hiring, retention, performance management, training, and education
- Provide leadership, mentorship, and coaching to Coders, Clinical DRG Auditors, and Nurse Reviewers
- Monitor aging inventory, workload, assignments, productivity, quality, service level agreements, contract deliverables, and timelines
- Evaluate productivity, utilization, efficiency, finding rates, savings, appeal overturn rates, and completed reviews
- Meet with clients and providers regarding complex cases, trend analysis, exit conferences, and settlement conferences
- Serve as a subject matter expert for new tools, automation, product development, and clinical readiness
- Resolve escalated issues and analyze reports and data to identify trends and resources
- Manage and evaluate individual and team performance and take appropriate action
- Perform other assigned functions
Requirements:
- Active, unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license under the Nurse Licensure Compact (NLC), or CPC, CCS, or CPMA certification required
- Bachelor's degree in business, healthcare administration, or related field preferred
- 5+ years of healthcare experience with increasing responsibility required
- 3+ years of utilization review or healthcare auditing experience preferred
- 2+ years of management or supervisory experience preferred
- Thorough understanding of clinical criteria and clinical review judgment
- Ability to work remotely within the United States
- Ability to travel up to 20%
Benefits:
- Flexible hours/work flexibility
- Work-life balance
- Continuous learning and career development
- Generous, flexible vacation policy
- 401(k) employer match
- Comprehensive health benefits
- Educational assistance
- Leadership and technical development academies
- Up to 20% travel
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