Clinical Operations Program Manager – Clinical Appeals

Job not on LinkedIn

🔥 12 hours ago

🇺🇸 United States – Remote

💵 $113k - $197.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥 Clinical Operations

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Manage and prioritize operational projects, market support activities, Clinical Appeals or UM support needs, audit-related deliverables, compliance initiatives, workflow improvements, and system/process enhancement requests • Support delivery of Utilization Management and Clinical Appeals operational initiatives through project planning, workflow development, implementation coordination, stakeholder engagement, and post-implementation support • Partner with market leadership, UM Operations, and Clinical Appeals stakeholders on new market implementations, product changes, operational readiness, issue resolution, and market-specific needs • Collaborate with Training and Auditing teams on audit tools, audit readiness, process documentation, quality monitoring, trend identification, and remediation planning • Track regulatory and contractual requirements, coordinate workflow and documentation updates, monitor risks, and escalate barriers • Coordinate project requirements, reporting needs, process changes, and system impacts with internal stakeholders • Maintain project plans, action logs, issue trackers, status updates, and project management tools • Support business activities, market launches, operational transitions, and implementation efforts through requirements coordination, workflow development, communications, testing, training, and post-go-live follow-up • Perform source system validation and data verification for audit responses • Participate in regulatory audits; retrieve and validate supporting documentation; validate workflows against policies and procedures • Analyze operational and regulatory UM and appeals data; review and validate regulatory reports; identify discrepancies and root causes; implement corrective actions; support reporting submission readiness • Support action plans and process improvement initiatives based on audit feedback, reporting trends, stakeholder feedback, and workflow performance • Provide status reporting, program and project metrics, business decision documents, and communications to senior management, stakeholders, executive sponsors, and impacted business areas • Represent UM Operations and Clinical Appeals in intake, governance, prioritization, and cross-functional workgroups • Coordinate vendor-related operational activities, including onboarding, issue resolution, workflow integration, and performance monitoring • Manage program and project documentation, including SharePoint sites, repositories, meeting materials, decision logs, project artifacts, and operational reference materials • Perform other job-related duties as requested

🎯 Requirements

• Bachelor's degree in nursing, business management, or related field required • Equivalent years of relevant work experience may be accepted in lieu of required education • Five (5) years of healthcare experience required • Two (2) years of project management, program management, operational implementation, or cross-functional business support experience required • Experience supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance activities, clinical systems, or healthcare payer operational projects preferred • Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook • Demonstrated skills in project management, workflow design, operational implementation, process improvement, and cross-functional coordination • Knowledge of Utilization Management and/or Clinical Appeals • Strong knowledge of the healthcare payer industry, Medicaid, and Medicare • Ability to understand and implement regulatory and contractual requirements • Knowledge of audit readiness, quality monitoring, regulatory compliance, market operations, Utilization Management or Clinical Appeals, and healthcare payer operational workflows • Clinical licensure required • Registered Nurse (RN) license preferred • Six Sigma Certification preferred • Ability to analyze processes across multiple functional areas • Ability to document, track, and manage business requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle • Ability to work independently and within a team environment

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support • Occasional travel opportunities up to 15% based on department needs