Manager, Complex Clinical Review Machinify

Key Responsibilities

• Oversee the Complex Clinical Bill Review team, managing production expectations, SLA’s, client communication, and team performance.
• Analyze and track internal business requirements and processes through document and workflow analysis.
• Continuously evaluate the functionality across multiple programs to ensure efficient and accurate reviews.
• Perform requirements gathering to problem solve for any process-related issues that require attention from development.
• Manage team member’s current assignments and collaborate across teams/departments for timeliness to ensure all internal and external SLAs are met.
• Oversee the development and application of clinical review concepts, such as experimental and investigational, pharmacy utilization, level of care, medical appropriateness, and medical policy adherence.
• Delegate tasks and responsibilities to team members and oversee specials projects that involve the team.
• Coordinate system enhancements for the clinical review team, including JIRA ticket creation, UAT testing, and production employment.
• Monitor team’s performance, tracking and trending the metrics of the team to identify opportunities for growth and efficiency.
• Identify the needs of team members, paying special attention to issues that require attention from IT.
• Develop and coordinate training materials, quality assurance process, and dispute response workflows for the team.
• Support internal operations to keep the team abreast of any organizational or client policy changes.
• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.
• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.
• Coordinate and contribute to the dispute resolution process for all clinical appeals received.
• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.
• Act as liaison between the Operations team and Client Success team in order to quickly address and resolve any client related issues.
• Effectively ensures adherence to medical review guidelines and training requirements of staff.
• Provides support as needed to ensure auditors are equipped with tools and resources required to perform clinical audits.
• Complete and conduct performance reviews for assigned staff.
• Conduct team meetings with direct reports on a regular basis.
• Organize and coordinate the onboarding of all new team members.
• Other duties as assigned.