Manager, Complex Clinical Review

🕒 Setembro 2

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $115.000 - $130.000 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

🦅 Patrocina Visto H1B

Esta empresa já patrocinou vistos H1B no passado.

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Machinify

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

🏥 Saúde

💼 Consultoria

📦 Logística

💰 $10.000.000 Series A - Machinify em 2018-10

Healthcare • Consulting • Logistics

A Machinify é uma empresa de plataforma e serviços de IA focada em saúde que transforma pagamentos e a integridade de pagamentos no setor. Seu sistema operacional de IA unifica reivindicações, prontuários médicos, contratos e políticas, utilizando modelos fundamentais e agentes específicos de tarefas para automatizar e aprimorar a codificação, precisão de pagamentos, recuperações e prevenção de custos. A Machinify atende planos de saúde (incluindo 18 dos 20 maiores), oferece implantações internalizadas, híbridas ou totalmente gerenciadas e enfatiza resultados mensuráveis — relatando mais de 85 clientes, 270 milhões de vidas cobertas e mais de 6 bilhões de dólares em prevenção de custos e recuperações anuais.

Descrição

• Oversee the Complex Clinical Bill Review team, managing production expectations, SLAs, client communication, and team performance • Analyze and track internal business requirements and processes through document and workflow analysis • Evaluate functionality across multiple programs to ensure efficient and accurate reviews • Perform requirements gathering to resolve process-related issues requiring development support • Manage team assignments and collaborate across teams and departments to meet internal and external SLAs • Oversee development and application of clinical review concepts, including experimental and investigational, pharmacy utilization, level of care, medical appropriateness, and medical policy adherence • Delegate tasks and oversee special projects • Coordinate system enhancements, including JIRA ticket creation, UAT testing, and production deployment • Monitor team performance metrics to identify growth and efficiency opportunities • Identify team member needs, including issues requiring IT attention • Develop and coordinate training materials, quality assurance processes, and dispute response workflows • Support internal operations regarding organizational or client policy changes • Maintain current knowledge of medical practice, technology, regulations, legislation, and business trends • Perform audit quality assurance reviews as needed • Coordinate and contribute to clinical appeals dispute resolution • Recommend cost-saving and outcome-improvement opportunities • Liaise between Operations and Client Success to resolve client issues • Ensure adherence to medical review guidelines and staff training requirements • Equip auditors with required tools and resources • Complete performance reviews for assigned staff • Conduct regular team meetings with direct reports • Organize onboarding for new team members • Perform other duties as assigned

🎯 Requisitos

• 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 • Broad and comprehensive understanding of audit standards, policies and regulations, including medical chart reviews • Strong project management and interpersonal skills • Ability to prioritize and multitask • Strong effective communication skills, both orally and in writing • Proven experience 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 engaging development teams

🏖️ Benefícios

• Work from anywhere in the US • Full Medical/Dental/Vision for employees & their families • Flexible and trusting environment • Unlimited FTO • Competitive salary • Equity • 401(k) including employer match