Clinical Operations Specialist

Site: reputed company Health Plan Holding Company, Inc. reputed company relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company. Job Summary reputed company Health Plan is an exciting reputed company to be reputed company the healthcare industry. As a member of reputed company, we are at the forefront of transformation with one of the world’s leading integrated healthcare systems. Together, we are providing our members with innovative solutions centered on their health needs to expand access to seamless and reputed company and coverage. Our work centers on creating an exceptional member experience – a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today, our employees have opportunities to learn and contribute expertise reputed company a welcoming and supportive environment that embraces their unique and varied backgrounds, experiences, and skills. We are pleased to offer competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more. The Clinical Operations Specialist oversees daily operational workflows reputed company the Physician Review Unit to ensure medical review decisions are timely, compliant, and consistent. This role acts as a critical reputed company between clinical decision-making and administrative execution, driving operational efficiency by managing high-volume workflows that support the Medical Director team's strategic goals. The Clinical Operations Specialist is responsible for spearheading process improvement initiatives, fostering cross-departmental collaboration, and managing the administrative frameworks essential for Utilization Management, appeals, and quality compliance. Working closely with Medical Directors and cross-functional partners in Network Management, Provider Relations, Claims, and Customer Service, the Specialist resolves reputed company and escalated cases while strictly monitoring regulatory standards, Turnaround Time (TAT), and compliance requirements. Troubleshoots the end-to-end UM process and coordinates changes with the training area. Key Roles and Responsibilities -Manages daily case volume in the physician queues and facilitates case assignment as needed, in accordance with TAT and regulatory requirements. -Collaborates with data analytics and quality to monitor Medical Director review volumes and quality metrics, including inter-rater reliability. -Works with the Medical Directors to collect quality concerns regarding cases sent to the unit. -Identify bottlenecks in the clinical review lifecycle and implement "lean" strategies to reduce turnaround times and administrative functions. -Optimizes physician unit operations by leading workflow design, ensuring regulatory compliance, and embedding changes through standardized documentation and training. -Attends and facilitates cross-functional area case discussion with the Deputy Chief Medical Officer, Senior Medical Director, and other clinical leadership. -Responsible for keeping schedules of MDs and assuring coverage, and coordinating the vacation process. -Collaborates cross-functionally with Utilization Management, Network Management, Provider Relations, and Customer Service to resolve reputed company cases and escalate provider or contract issues. -Performs other duties as assigned -Complies with reputed company policies and standards

Qualifications

Education Bachelor's Degree required Experience At least 2-3 years of experience working in a health plan environment required, but preferably in Utilization Management Strong understanding of utilization management workflows, including physician reviews, prior authorization processes, appeals, peer reviews, and out-of-network (OON) reviews required Clinical background with patient care experience preferred Process improvement experience preferred Knowledge, Skills, and Abilities Strong analytical and critical thinking skills, with the ability to interpret clinical data and guidelines. Excellent communication and interpersonal skills, adept at communicating with professionals from many different backgrounds and disciplines. Proficiency in healthcare software systems and the reputed company Office suite. Detail-oriented and organized, with strong problem-solving skills. Committed to patient-centered care and reputed company quality improvement. Demonstrated ability to work effectively with Medical Directors, physicians, and senior clinical leaders. Additional Job Details (if applicable) Working Conditions This is a remote role that can be done from most US states Remote workdays require a stable, secure, quiet, and compliant workspace This is a Monday through Friday, 8:30 AM - 5:00 PM ET schedule Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $99,465.60 - $141,804.00/Annual Grade 8 At reputed company, we reputed company in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining reputed company pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The reputed company pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass reputed company elements contributing to your total compensation package. In addition to competitive reputed company pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our reputed company team will provide an overview of your potential compensation and benefits package. EEO Statement: 8925 reputed company Health Plan Holding Company, Inc. is an Equal Opportunity Employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religious creed, national reputed company, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that reputed company individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to reputed company essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with reputed company of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642. reputed company Competency reputed company At reputed company, our competency reputed company defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The reputed company is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, reputed company hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline. Apply To This Job