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Clinical Review Manager (337-889)


This is a Contract position in Houston, TX posted April 27, 2019.

MAJOR RESPONSIBILITIES Enables team members to ensure consistent quality service to providers and members Manages staff with varying professional licenses and education levels Oversees and collaborates with other managerial staff in the department Give direction to and supervise others by offering approaches to be used and following up to ensure timely and quality execution against expectations Proposes, implements, and ensures adherence to approved process changes designed to meet business needs Facilitates an employee-oriented company culture that emphasizes quality, continuous improvement, key employee retention and development and high performance Delegates work to employees, tracks progress and provides constructive feedback in a timely manner Leads employees using a performance management and development process designed to provide an overall context and framework to encourage and enhance organizational value Leads employees to meet the organization’s expectations for productivity, quality, and goal accomplishment Ensures that effective performance feedback is provided through employee recognition, rewards, and disciplinary action Establishes and maintains relevant controls and feedback systems to monitor the operation of the department as well as assigned program(s) Continuously tracks and monitors team and individual performance, in conjunction with Supervisory staff, and provides feedback and coaching to ensure performance goals are achieved Communicates with employees, other departments or staff regarding how to effectively research and resolve issues Communicates with employees and/or clients to ensure prompt and courteous attention to all questions regarding products and services Attends meetings in relation to program, project scope or as required Appropriately communicates organization information through department meetings, one-on-one meetings, appropriate email and regular interpersonal communication Provides regular operational updates to senior level managers Develops project scopes and objectives, involving all relevant stakeholders Develops a detailed project plan to track progress Oversees, reviews, or handles disciplinary actions in relation to staff, e.g., verbal warnings, records of discussion, and formal disciplinary documentation.

Collaborates with human resources to ensure adherence to company policies.

Responsible for knowing the intricacies of all benefit management programs including applicable regulatory compliance, accreditation standards, and client/health plan service level requirements for each program, line of business, and geographic region Assists with CMS ODAG and SARAG validation & clinical decision documentation audits upon request Assists with URAC and NCQA clinical file audits upon request Assists with service restoration efforts during emergencies Manages and ensures adherence to all company policies and procedures, including payor
– specific turnaround times (TAT) Refers all complaints to Compliance Officer; works collaboratively with the Quality Department to investigate complaints and correct errors Participates in the Quality Management Program as appropriate Promotes business focus which demonstrates an understanding to the company’s vision, mission and strategy Utilizes knowledge of telephony, ACD, workforce, and related systems to manage daily phone metrics Required Skills OTHER DUTIES Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.

Duties, responsibilities and activities may change at any time with or without notice.

QUALIFICATIONS Graduate of an accredited school of nursing Current active unrestricted RN license in a state or territory of the United States required Minimum 3 years’ experience in an acute care or managed care setting required Experience in team interactions and improvement methods/projects (e.g., coaching, quality and productivity) Ability to work in a fast-paced, evolving environment; on-call after hours work may be required Experience in conflict resolution Minimum of 2 years of progressively responsible supervisory experience in a managed care environment preferred Strong interpersonal skills at both individual and team level Excellent oral and written skills Proficient leadership and facilitation skills Ability to utilize critical thinking skills Excellent organizational skills ENVIRONMENT AND PHYSICAL DEMANDS Business office environment or HIPAA compliant remote location Ability to use telephone for up to 8 hours unassisted Ability to sit for up to 8 hours unassisted Ability to enter data for up to 8 hours unassisted Ability to view PC screen for up to 8 hours Ability to prioritize in a multi-task environment Relocation Offered SDL2017