Clinical Operations Manager – Utilization Review

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥 Clinical Operations

👻 Ghost score 25%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Dane Street

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

Dane Street is a national leader in Independent Medical Exams and Reviews, providing objective, compliant, and timely Independent Medical Examinations, Peer Reviews, and other medical reports. With a large network of over 16,000 physicians, the company offers its services across 25,000 locations and 100 specialties, including Workers' Compensation, Auto, Liability, and Disability claims. Dane Street supports Insurance Carriers, Third Party Administrators, Managed Care Organizations, and Federal/State entities with expert medical analyses, helping them make accurate determinations. The company is recognized for its quality, fast turnaround times, and efficient processes, earning accolades like the NCQA Accreditation in Utilization Management and the Great Place to Work certification.

📋 Description

• Lead day-to-day operations for Dane Street’s Group Health division • Direct workflow, staffing, prioritization, and timely completion of utilization and independent clinical reviews • Oversee Utilization Review Nurses, Clinical Quality Assurance Specialists, Customer Service Representatives, and other operational staff • Manage referral intake, clinical review preparation, quality assurance, client communication, and case completion • Provide clinical and utilization review guidance and first-line support for complex process questions • Ensure compliance with client requirements, internal procedures, regulatory requirements, and utilization management workflows • Support new client implementations, volume expansions, and changes in client requirements • Monitor turnaround time, productivity, quality, service levels, and client-specific KPIs • Analyze operational data to identify trends, capacity constraints, performance gaps, and improvement opportunities • Set performance expectations, coach employees, conduct evaluations, and manage corrective action or performance improvement plans • Recognize high performers and support succession and professional development • Partner with Quality Assurance, Training, and clinical leadership on quality improvement, education, root cause analyses, and corrective actions • Identify workflow inefficiencies and implement scalable process improvements • Monitor referral volumes and adjust resources and priorities to maintain service levels • Evaluate staffing needs and recommend operational adjustments • Partner with leadership and Human Resources to recruit, interview, select, and onboard team members • Support workforce planning for new business, client growth, and operational scope changes • Resolve client questions, escalations, and operational concerns • Collaborate with Medical Directors, Account Management, Training, Quality Assurance, Network Management, Human Resources, Finance, IT, and Business Analytics • Communicate operational risks, trends, resource needs, staffing forecasts, and recommendations to leadership • Participate in client and internal meetings as an operational and clinical expert

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license required • Bachelor’s degree in Nursing, Healthcare Administration, Business Administration, or a related field preferred • Utilization Review/Utilization Management experience required • Healthcare operations leadership or people-management experience in a fast-paced, high-volume environment required • Experience managing operational KPIs, including productivity, quality, turnaround time, and service-level performance required • Ability to serve as a clinical and utilization management subject matter resource for clinical and non-clinical teams • Experience leading multidisciplinary teams that include clinical and non-clinical staff • Working knowledge of medical necessity review, utilization management principles, and healthcare payer operations • Experience coaching employees, managing performance, and developing high-performing teams • Health plan, managed care, or payer experience strongly preferred • Experience with prior authorization, medical necessity review, appeals, and/or independent review services preferred • Experience managing remote teams preferred • Experience supporting client implementations, operational growth, or rapidly changing referral volumes preferred • Reliable high-speed internet service capable of supporting a fully remote work environment • Ability to maintain a secure and uninterrupted remote workspace in accordance with company requirements • Ability to perform duties involving prolonged sitting and computer work

🏖️ Benefits

• Medical, dental, and vision coverage for employees and their families • Voluntary life insurance options for employees, spouses, and children • Hospital indemnity, critical illness, accident indemnity, and pet insurance plans • Basic life insurance at no cost • Short-term disability coverage at no cost • Long-term disability coverage at no cost • Generous paid time off policy • 401k plan with company match • Apple equipment for remote workspace • Media stipend for remote workspace • Collaborative remote culture • Professional growth opportunities • Commitment to employee development