Note: The job is a remote job and is open to candidates in USA. Machinify is a healthcare intelligence company that delivers AI-powered solutions and expertise across the healthcare payment continuum. The Manager, Complex Clinical Review will lead a remote team conducting clinical review audits, manage operational performance and client requirements, and oversee quality, staffing, training, appeals, and process improvement initiatives.
Responsibilities
- 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
Skills
- Current, unrestricted nursing license in good standing is required
- Certified coding certification 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
- 3+ years relevant supervisory or leadership experience in similar business environment, preferred
- Experience managing remote staff is a plus
Benefits
- 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
- Equity
- 401(k) including employer match
Company Overview
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