Note: The job is a remote job and is open to candidates in USA. ExamWorks is seeking a Clinical Operations Manager to lead a remote team and provide clinical leadership across utilization management and No-Fault (PIP) programs. The role focuses on ensuring compliant, high-quality service delivery, improving workflows and clinical programs, and partnering with operational leaders, physicians, and clinical experts to support client and patient outcomes.
Responsibilities
- Oversee departmental operations to ensure services are delivered effectively and in compliance with all regulatory requirements, company policies, and HIPAA standards
- Ensure daily workflow is managed efficiently and adjust as necessary to achieve quality, productivity, and service goals
- Maintain control of operating expenses and resources to support departmental and organizational objectives
- Create and provide support, training, tools, and resources to assist staff in achieving departmental excellence and maintaining company standards
- Review and analyze quality assurance and performance data and implement improvement strategies to enhance quality, consistency, and productivity
- Serve as the department's clinical subject matter expert regarding treatment trends, industry best practices, and regulatory requirements
- Maintain knowledge of New Jersey AICRA and Michigan PIP regulations and ensure operational processes align with applicable requirements
- Collaborate with physician panel members and consulting clinical resources to support quality initiatives, clinical consistency, and program development
- Monitor clinical and treatment trends and recommend process improvements and operational enhancements
- Oversee and assist, as needed, with the resolution of provider appeals and escalated clinical issues
- Organize and participate in staff meetings and promote effective communication across all lines of business
- Respond promptly to customer service needs and resolve complex customer service situations
- Ensure staff receives timely communication regarding client-specific requirements, operational changes, and special instructions
- Ensure organizational activities and operations comply with applicable local, state, and federal laws and regulations
- Perform other duties as assigned
Skills
- Experience within the PIP, No-Fault, Workers' Compensation, or managed care industry
- Prior leadership or management experience
- A track record of developing or improving operational processes and clinical programs
- Strong knowledge of utilization review and regulatory compliance
- The ability to collaborate across teams and influence positive change
- Minimum of six years related clinical experience, including at least three years of leadership or management experience; or equivalent combination of education and experience
- Active unencumbered Registered Nursing license required
- Must possess strong knowledge of medical terminology, anatomy and physiology, medications, laboratory values, and evidence-based treatment practices
- Must possess general knowledge of automobile claims regulations as they relate to No-Fault (PIP) programs and utilization review practices
- Must possess working knowledge of nationally recognized treatment guidelines and evidence-based clinical review resources utilized in utilization review operations
- Must possess a working knowledge of medical records, health information principles, and medical-legal documentation
- Must possess strong analytical skills and the ability to evaluate operational, quality, and productivity data to support departmental goals and performance outcomes
- Must demonstrate strong critical thinking, clinical judgment, and decision-making abilities
- Ability to follow instructions and respond appropriately to management direction
- Must be proficient in Microsoft Word, Outlook, Excel, Internet applications, and other business-related software programs
- Must possess excellent verbal, written, and interpersonal communication skills
- Must be able to effectively communicate and collaborate with physicians, healthcare providers, clients, and internal stakeholders
- Must demonstrate accuracy, thoroughness, accountability, and a commitment to quality while identifying opportunities for continuous improvement
- Must exercise sound judgment, make informed decisions, and appropriately involve others in the decision-making process
- Must be able to work independently, prioritize responsibilities, and manage multiple competing priorities
- Must possess strong analytical and problem-solving skills, including the ability to evaluate clinical, operational, and quality-related information and implement effective solutions
- Must maintain confidentiality and handle sensitive information appropriately
- Must be able to foster and promote a positive, team-oriented work environment
- Must be able to remain focused and productive in a fast-paced environment with frequent interruptions
- Must be able to perform effectively under pressure and meet established deadlines
- Must be able to adapt to changing priorities, manage change effectively, and respond appropriately to unexpected situations
- Bachelor's degree in nursing, business management, healthcare administration, or related field preferred
- Experience in utilization review, clinical operations, and insurance-related healthcare services preferred
- Knowledge of the insurance industry and no-fault (PIP), workers' compensation, liability, and disability claims environments preferred
- Detailed knowledge of New Jersey AICRA and Michigan PIP regulations is preferred
Benefits
- 100% fully remote
- Medical, vision, and dental benefits
- Paid time off
- 401k
Company Overview