Note: The job is a remote job and is open to candidates in USA. Dane Street provides independent medical exams and peer review programs that support claims management and medical determinations for healthcare and insurance organizations. The Clinical Operations Manager will lead the Group Health division by overseeing utilization review operations, clinical quality, staffing, performance management, client partnerships, and continuous process improvement in a remote, high-volume environment.
Responsibilities
- Lead day-to-day operations for the assigned Group Health division, ensuring appropriate workflow, staffing, prioritization, and timely completion of work
- Oversee Utilization Review Nurses, Clinical Quality Assurance Specialists, Customer Service Representatives, and other assigned operational staff
- Manage the end-to-end operational workflow, including referral intake, clinical review preparation, quality assurance, client communication, and case completion
- Serve as a clinical and utilization review subject matter resource for the team, providing guidance on clinical review workflows, utilization management principles, and complex or unusual case scenarios
- Provide first-line support for clinical and process questions from clinical and non-clinical staff, escalating to Medical Director or senior clinical leadership when appropriate
- Ensure operational and clinical processes align with client requirements, internal procedures, applicable regulatory requirements, and established utilization management workflows
- Support new client implementations, volume expansions, and changes in client requirements
- Lead the team through changing priorities, workflow demands, and business needs while maintaining service and quality expectations
- Monitor and manage key performance indicators, including turnaround time, productivity, quality, service levels, and client-specific performance requirements
- Use operational data and reporting to identify trends, capacity constraints, performance gaps, and opportunities for improvement
- Establish clear individual and team performance expectations and ensure accountability for established goals
- Provide ongoing coaching, feedback, and performance management to team members
- Develop and oversee corrective action or performance improvement plans when appropriate
- Conduct timely and constructive performance evaluations
- Recognize and develop high-performing team members and support succession and professional development opportunities
- Provide leadership with regular updates regarding operational performance, staffing, capacity, risks, and improvement initiatives
- Partner with Quality Assurance, Training, and clinical leadership to maintain consistent, high-quality clinical review processes
- Monitor quality trends and identify recurring clinical, operational, or knowledge gaps
- Provide clinical and operational guidance to address identified trends and improve team performance
- Partner with Training and Quality leadership to develop education, reference materials, and process improvements when recurring opportunities are identified
- Support root cause analyses, corrective action plans, and client remediation efforts when needed
- Identify workflow inefficiencies and implement process improvements designed to improve quality, productivity, consistency, and scalability
- Promote adherence to client-specific guidelines, health plan requirements, internal policies, and applicable regulatory standards
- Monitor referral volumes and workload throughout the day and adjust resources and priorities as needed to maintain turnaround time and service-level requirements
- Evaluate staffing needs based on referral volume, productivity, client requirements, and anticipated growth
- Proactively identify capacity risks and recommend staffing or operational adjustments
- Partner with leadership and Human Resources to recruit, interview, select, and onboard qualified team members
- Maintain appropriate staffing and coverage to support client requirements and fluctuations in referral volume
- Support workforce planning associated with new business, client growth, and changes in operational scope
- Support timely resolution of client questions, escalations, and operational concerns
- Partner with Account Management and leadership to address client needs and maintain strong service performance
- Collaborate with Medical Directors, Training, Quality Assurance, Network Management, Human Resources, Finance, IT, Business Analytics, and other departments to support operational objectives
- Communicate operational risks, trends, and resource needs proactively to leadership
- Participate in client and internal meetings as needed to provide operational and clinical expertise
Skills
- * Active, unrestricted Registered Nurse (RN) license required
- * Utilization Review/Utilization Management experience required
- * Healthcare operations leadership or people-management experience in a fast-paced, high-volume environment required
- * Demonstrated experience managing operational KPIs, including productivity, quality, turnaround time, and service-level performance required
- * Demonstrated ability to serve as a clinical and utilization management subject matter resource for clinical and non-clinical teams
- * Experience leading multidisciplinary teams that include clinical and non-clinical staff
- * Strong working knowledge of medical necessity review, utilization management principles, and healthcare payer operations
- * Experience coaching employees, managing performance, and developing high-performing teams
- Reliable high-speed internet service capable of supporting a fully remote work environment
- Ability to maintain a secure and uninterrupted remote workspace in accordance with company requirements
- * Bachelor's degree in Nursing, Healthcare Administration, Business Administration, or a related field preferred
- * Health plan, managed care, or payer experience strongly preferred
- * Experience with prior authorization, medical necessity review, appeals, and/or independent review services preferred
- * Experience managing remote teams preferred
- * Experience supporting client implementations, operational growth, or rapidly changing referral volumes preferred
Benefits
- Medical, dental, and vision coverage for you and your family.
- Voluntary life insurance options for you, your spouse, and your children.
- Voluntary hospital indemnity, critical illness, accident indemnity, and pet insurance plans.
- Basic life insurance at no cost to employees.
- Short-term disability coverage at no cost to employees.
- Long-term disability coverage at no cost to employees.
- Generous paid time off policy.
- 401k plan with a company match.
- Apple equipment provided for remote workspace.
- Media stipend provided for remote workspace.
- Collaborative remote culture.
- Professional growth opportunities.
- Commitment to employee development.
Company Overview