[Remote] Clinical Operations Specialist

Note: The job is a remote job and is open to candidates in USA. reputed company Health Plan is a leading integrated healthcare system focused on providing innovative solutions to enhance member care. The Clinical Operations Specialist oversees daily operational workflows reputed company the Physician Review Unit, ensuring timely and compliant medical review decisions while driving process improvements and collaboration across departments.

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

Skills

• Bachelor's Degree required
• 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
• 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
• Clinical background with patient care experience preferred
• Process improvement experience preferred

Benefits

• Competitive salaries and a benefits package with flexible work options, career growth opportunities, and much more
• Comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth
• Remote role that can be done from most US states
• 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

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