Manager, Clinical Operations

Role Description

Manager, Clinical Operations

Manager II - BPM

Who We Are

Founded in 2016, we’ve become a trusted and valued partner for health plans and providers. We offer a modern integrated ecosystem of healthcare operations, processes, and products, with inherent scalability, efficiency, and predictable outcomes. Our BPaaS delivery solutions work behind the scenes to manage our customers’ complex admin operations, giving them elbow room to focus on their members’ needs and well-being.

Bending cost curves, guaranteeing outcomes, finding paths through roadblocks – that’s our way of life. Our customers count on us to safely navigate them through deadlocks. We have a strong global presence and a dedicated workforce of 4000+ people spread across the world.

Our brand is built on strong foundations of simplicity, honesty, and leadership, and we stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are

The Manager, Clinical Operations is responsible for management and oversight of staff who provide operational support and analysis and on behalf of health plan customers for Utilization Management, Quality Improvement and other programs requiring clinical oversight. This position provides effective and efficient solutions to complex business problems and responsibilities include maintaining effective relationships within and across teams, key vendors, and clients to ensure that the issues and needs of Medicare Advantage, Commercial and Medicaid are represented and prioritized in all clinical programs. This role is also responsible for strategizing, innovating, analyzing, planning, organizing, budgeting, reporting, and other functions that are required to maintain and operate an efficient and effective team.

The Opportunity

• Management and oversight of a clinical team conducting medical management and services across multiple locations
• Oversight of key metrics, including quality, productivity, and compliance
• Responsible for the successful execution of the Quality Improvement Program in accordance with CMS requirements including development, management and submission of Chronic Condition Improvement Program (CCIP) and the Quality Improvement Plan (QIP) as well as the annual work plan and evaluation.
• Acts as primary point of contact for all related compliance audits on behalf of medical management programs including organization determinations, timeliness, and readiness.
• Plans, organizes, and directs activities of Medical Management, including, but not limited to, planning, training, motivation, staff development, staff selection, and communication.
• Provides or orchestrates the provision of subject matter expertise and support related to medical management inquiries within requests for proposals and customer presentations
• Maintains and promotes quality relationships with internal and external customers.
• Compiles and analyzes statistics and prepares activity related reports, staffing needs, and inventories and monitors workflows within the unit.
• Leads and participates in workgroups and task forces in order to complete special assignments and projects.
• Resolves high priority inquiries– including issues of non-compliance with related vendors or programs.
• Recommends processes to control expenditures and promotes efficient use of resources.
• Participates in development of annual departmental budget, monitors budget, and identifies budget discrepancies. Researches cause and makes recommendations.
• Responsible for balancing workload to optimize the effectiveness of the department.
  
  

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need

• Bachelor’s degree in Business Administration, Health Care Administration, or a related field.
• Master’s degree in a related field is preferred.
• Clinical background (e.g. RN) and/or CPHQ certification required.
• Valid and unrestricted driver’s license is required.
• Continuous learning, as defined by the Company’s learning philosophy, is required.
• Ten years of experience with progressive responsibility in healthcare administration or a health plan with demonstrated technical knowledge that provides the necessary knowledge, skills, and abilities required.
• Five years management experience in Medical Management required with a focus on Utilization Management.
• Ability/willingness to develop, recommend and execute solutions to ad hoc issues and challenges that may arise with a process efficiency mindset.
• Strong knowledge of clinical and quality improvement processes and concepts.
• Subject matter expertise in Medicare Advantage and Utilization Management
• Ability and willingness to delegate, guide and oversee work of team on projects.
• Excellent analytical, organizational, planning, verbal, and written communication skills required.
• Proficient in work that involves analysis, organization, planning, presentation development, problem resolution, sales, strategy, and innovation.
• Must be self-motivated, results-oriented and can work well under pressure with multiple clients and multiple systems
• Ability to effectively present information and respond to questions from internal and external contacts at all levels of the organization.
• Proficient in current industry standard PC applications and systems and medical management systems.
• Extensive knowledge of operations and ability to lead a team to meet industry standard SLA’s and metrics.
• Must demonstrate leadership ability and team building skills to effectively supervise professional and non-professional staff and interact with all levels of management.
• Ability to work with and empower others on a collaborative basis to ensure success of unit team.
• Ability to effectively exchange information, in verbal or written form, by sharing ideas, reporting facts and other information, responding to questions, and employing active listening techniques.
• Ability to effectively present budgetary and/or cost information and respond to questions as appropriate.
• Ability to establish workflows, manage multiple projects, and meet necessary deadlines.
• Ability to maintain confidentiality.
• Ability to manage both an onshore and offshore team effectively.
• Ability to operate a streamlined efficient team in multiple locations and time zones.
  
  

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by applicable law, UST Healthproof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range: $100,000-$126,000

Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serves as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

Simplicity

Simplifying complexity underlines everything we do - this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.

#Healthproof

#CB

Skills

Adhoc,Case Management,Analytical,Planning