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Health Clinical Services Senior Manager
2 weeks ago
About the Role:
We are seeking an experienced and dedicated clinical operations manager to lead our teams in ensuring high-quality, compliant, and efficient healthcare service reviews. In this pivotal role, you will oversee teams responsible for pre-service, concurrent, and retrospective medical necessity reviews, playing a key part in delivering exceptional service to our members and partners. If you are a licensed RN with strong leadership experience and a passion for improving healthcare operations, we encourage you to apply.
Key Responsibilities:
- Lead teams conducting various types of clinical reviews, including:
- Pre-service, concurrent, retrospective, and out-of-network reviews.
- Appropriateness of treatment setting assessments.
- Post-service claims reviews for medical necessity and contractual compliance.
- Ensure all reviews align with applicable medical criteria, policies, member benefits, and contractual guidelines.
- Manage service requests received via inbound calls and fax, and initiate outbound provider calls as needed to collect essential clinical information.
- Foster a collaborative and efficient team environment, promoting accuracy, compliance, and continuous improvement.
Qualifications & Skills:
- Licensure: Must possess a current and unrestricted U.S. Registered Nurse (RN) license. No specific state licensure is required.
- Experience:
- Minimum of 12 years in clinical operations or a related healthcare field.
- At least 10 years of proven supervisory or team leadership experience.
- Experience in Business Process Outsourcing (BPO) environments is highly valued. Health account experience is a plus but not mandatory.
- Candidates with diverse backgrounds, including both BPO and non-BPO settings, are encouraged to apply.
- Eligibility:
- Must be currently residing in the Philippines and possess the legal right to work in the country.
- Candidates should demonstrate stable career progression. A history of frequent job changes (e.g., less than one year per company) may not align with the requirements of this role.
