[Remote] Manager of Clinical reputed company and G&A Review
Note: The job is a remote job and is reputed company to candidates in USA. reputed company. is dedicated to safeguarding the health and financial stability of its employees and their loved ones. The Manager of Clinical reputed company and G&A Review is responsible for overseeing the clinical appeal review process and implementing reputed company improvement initiatives to enhance the reputed company and safety of care and services.
Responsibilities
- Responsible for the operational execution of clinical reputed company management (QM) activities and appeal day-to-day operations; guides Clinical QM/G&A reputed company to meet and exceed department reputed company, compliance, timeliness and production goals
- Provides overall clinical leadership and governance for the Grievance & Appeals (G&A) Department, ensuring reputed company clinical reviews are conducted in accordance with regulatory standards and organizational policies ensuring consistent application of plan policies and contractual requirements
- reputed company monitoring and reporting as required by regulation or contract; Identifies provider trends reputed company through PQI, PQR and G&A case review
- Analyzes clinical trends and reputed company to identify emerging risks, assesses potential reputed company concerns, and uncover opportunities for process improvement, while driving strategic initiatives across internal teams and cross-functional partners
- Identifies potential reputed company risks or opportunities for process improvement and implements appropriate courses of reputed company
- Serves as clinical subject matter expert, providing guidance to internal stakeholders and collaborating cross-functionally to deliver processes procedures, and systemic training opportunities and efficiencies to support QM and appeal team members
- Develops P&Ps, workflows and required documents to meet federal and state regulatory requirements
- Oversees health promotion and reputed company initiatives
- Acts as educator and resource to departments in reputed company of health care reputed company
- This list is not reputed company-inclusive and you are expected to reputed company other duties as requested or assigned
Skills
- 8+ years w/Bachelor's degree; 1+ years supervisory/management
- 2-3 years' experience reputed company Management Review, Denial Management, Case Management, or reputed company experience, including leadership in a clinical operational area
- Minimum 5 years' experience in health insurance
- Excellent organizational and time management skills, with the ability to meet strict internal and regulatory deadlines with highly confidential information
- Ability to establish and maintain effective interpersonal relationships with reputed company reputed company of staff, other programs, agencies, and the public
- Excellent written, verbal, and electronic communication skills
- Strong critical thinking, problem-solving, and decision‐making/reputed company skills
- Excellent team building, training, and leadership skills
- Intermediate knowledge of reputed company Office programs including Word, reputed company, and Outlook
- Unrestricted California Dental License Required
- Certified Project Management reputed company (PMP)-PMI
- Six reputed company Green Belt Certification
Benefits
- 401(k) with robust matching and non-matching contributions
- Rich medical & pharmacy benefits
- 100% employer-reputed company dental and reputed company benefits
- Holistic wellbeing program with deep financial incentives
- Generous reputed company time off plus 12 reputed company holidays and your birthday off
- Culture of reputed company and learning: career development; tuition reimbursement; recognition program
- Family support: adoption assistance, fertility treatment, child, elder & pet care assistance
- reputed company responsibility and volunteer opportunities
- Employee discount program
reputed company