About the Opportunity
The ideal candidate leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Manager will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.
What You’ll Do
- Oversee the Complex Clinical Bill Review team, managing production expectations, SLA’s, client communication, and team performance.
- Analyze and track internal business requirements and processes through document and workflow analysis.
- Continuously evaluate the functionality across multiple programs to ensure efficient and accurate reviews.
- Perform requirements gathering to problem solve for any process-related issues that require attention from development.
- Manage team member’s current assignments and collaborate across teams/departments for timeliness to ensure all internal and external SLAs are met.
- Oversee the development and application of clinical review concepts, such as experimental and investigational, pharmacy utilization, level of care, medical appropriateness, and medical policy adherence.
- Delegate tasks and responsibilities to team members and oversee specials projects that involve the team.
- Coordinate system enhancements for the clinical review team, including JIRA ticket creation, UAT testing, and production employment.
- Monitor team’s performance, tracking and trending the metrics of the team to identify opportunities for growth and efficiency.
- Identify the needs of team members, paying special attention to issues that require attention from IT.
- Develop and coordinate training materials, quality assurance process, and dispute response workflows for the team.
- Support internal operations to keep the team abreast of any organizational or client policy changes.
- Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.
- Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.
- Coordinate and contribute to the dispute resolution process for all clinical appeals received.
- Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.
- Act as liaison between the Operations team and Client Success team in order to quickly address and resolve any client related issues.
- Effectively ensures adherence to medical review guidelines and training requirements of staff.
- Provides support as needed to ensure auditors are equipped with tools and resources required to perform clinical audits.
- Complete and conduct performance reviews for assigned staff.
- Conduct team meetings with direct reports on a regular basis.
- Organize and coordinate the onboarding of all new team members.
- Other duties as assigned.
What You Bring
Required Skills/Qualifications
- Current, unrestricted nursing license in good standing is required - certified coding certification is a plus.
- 3+ years relevant supervisory or leadership experience in similar business environment, preferred. Experience managing remote staff is a plus.
- 3+ years’ experience performing clinical audits of itemized bills.
- 3+ years’ diverse nursing experience providing direct care in an inpatient or outpatient setting.
- Proven experience with healthcare industry software products and process development.
- Experience managing multiple projects in a team environment.
- Possess a broad and comprehensive understanding of audit standards, policies and regulations, applies a broad and comprehensive knowledge in areas including, medical chart reviews.
- Strong project management and interpersonal skills, makes sound decisions, exhibiting initiative and intuitive thinking.
- Consulted often by others for advice and opinions and recognized as a leadership role model.
- Strong interpersonal skills for interfacing with all levels of internal and external audit teams and management.
- Ability to prioritize and multitask.
- Must be a strong effective communicator, both orally and in writing, with an energetic, charismatic and approachable style.
- Proven experience in managing high performing dynamic teams.
- Ability to work in a diverse and fast paced environment.
- Problem solving, strong analytical skills, people skills, teamwork, people management, and managing processes
- Strong working knowledge of Windows office systems including full Microsoft Suite and Teams.
- Advanced software skills in Microsoft Office (Excel).
- Experience with various forms of software and experience engaging development teams.
What We Offer
- Work from anywhere in the US! Machinify is digital-first.
- Full Medical/Dental/Vision for employees & their families
- Flexible and trusting environment where you’ll feel empowered to do your best work
- Unlimited FTO
- Competitive salary, equity, 401(k) including employer match