Executive Escalations, Clinical Review Manager

Job not on LinkedIn

October 26

🏄 California – Remote

Although this job is listed in California, this company may be open to hiring remote in other states.

🤠 Texas – Remote

Although this job is listed in Texas, this company may be open to hiring remote in other states.

💵 $92.4k - $166.3k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👔 Manager

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SCAN

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Healthcare Insurance • B2C

SCAN is a mission-driven healthcare organization focused on reinventing aging by delivering evidence-based, patient-centered care and coverage for older adults. It operates an integrated portfolio including health insurance plans with innovative benefits, in-home and virtual primary care, support programs for caregivers and homebound older adults, and specialized services for vulnerable populations. SCAN also invests in and partners with companies that advance care models and resources to help older adults remain healthy and independent at home.

1001 - 5000 employees

Founded 1977

⚕️ Healthcare Insurance

👥 B2C

📋 Description

• Responsible for leading the investigation, resolution, closure and summary reporting of member and provider complaints escalated through executive leadership, regulators, or legal channels. • Serve as the primary contact and accountable leader for the investigation, resolution, and response to high-visibility member complaints received through executive leadership. • Conduct Clinical Review of Member Interactions to Identify Quality of Care Concerns. • Partner with internal teams to conduct thorough root cause analyses and implement effective, sustainable resolutions. • Prepare clear, professional, and empathetic written responses on behalf of executive leadership for internal and external stakeholders. • Track and analyze escalation trends, with a focus on identifying patterns related to care quality, access, and service breakdowns. • Builds effective professional relationships with providers and other internal and external partners utilizing verbal and written communication skills. • Serves as a subject matter expert and represents the department in internal and regulatory audits.

🎯 Requirements

• Bachelor's Degree required • Registered Nurse (RN) • 2+ years Medicare/Medi-Cal experience in managed care environment. • Escalations and/or complaints handling experience. • Analytical and root cause investigation experience. • Executive level communication experience or demonstrated equivalent writing skills. • Cross-functional collaboration experience. • Grievance and appeals handling experience. • Knowledge of CMS and DHCS grievance and appeals regulations. • Quality auditing experience. • Case management experience in a medical group, IPA and/or HMO setting preferred. • Strategic Problem Solving - Resolves complex cases with sound judgment. • Executive Communication - Writes and speaks clearly, professionally, and persuasively. • Emotional Intelligence - Maintains empathy and calm under pressure. • Strong written and oral communication skills, as well as strong interpersonal, critical thinking, and analytical skills. • Bilingual ability is strongly recommended.

🏖️ Benefits

• Robust Wellness Program • Generous paid-time-off (PTO) - 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days • Excellent 401(k) Retirement Saving Plan with employer match • Robust employee recognition program • Tuition reimbursement