Associate Manager, Clinical Review

🕒 May 20

🤠 Texas – Remote

🤠 Texas – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👔 Manager

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Healthcare Insurance • Human Services • Healthcare

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Responsible for supervising the day-to-day prepay, post-pay, prior authorization, and medical record review activities of a multidisciplinary team of Coders, Clinical DRG Auditors, and Nurse Reviewers. • Oversees and manages the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality. • Consistently demonstrates effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; supporting those affected by change; monitoring transition and evaluating results. • Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills to provide best-in-class practices to enhance efficiency, quality, and customer satisfaction. • Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met. • Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements. • Meet with clients and providers to discuss complex cases, trend analysis, exit and/or settlement conferences. • Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues, and coach and mentor staff to develop a high-performing team. • Analyze reports and data and identify trends and resources that improve the delivery of clinical review services. • Manage and evaluate individual/team performance and take appropriate action to meet and/or exceed performance standards. • Perform other functions as assigned.

🎯 Requirements

• Active, Unrestricted RN license from the United States and in the primary home residency • active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) • Bachelor’s degree in business, healthcare administration, or related field preferred • 5+ year’s healthcare experience with increasing responsibility required • 3+ year’s utilization review or health care auditing experience required • 2+ year’s management or supervisory experience preferred • Demonstrates a thorough understanding of clinical criteria and clinical review judgment.

🏖️ Benefits

• Up to 20% Travel