Clinical Operations Program Manager - Clinical Appeals
New
J
JobgetherHealthcare Payer
Based in United StatesFull-TimeManager
SalarySalary range of $113,000 to $197,700.
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Job Details
- Experience
- At least 5 years of healthcare experience; at least 2 years of project/program management.
- Required Skills
- Project ManagementMicrosoft OfficeProcess improvement
Requirements
- Bachelor's degree in nursing, business management, or related field, or equivalent experience.
- Clinical licensure is required; active Registered Nurse (RN) license preferred.
- At least 5 years of healthcare experience.
- At least 2 years of experience in project management, program management, or operational implementation.
- Strong knowledge of the healthcare payer industry, specifically Medicaid and Medicare.
- Deep understanding of Utilization Management and/or Clinical Appeals processes and workflows.
- Demonstrated ability to manage project lifecycles, business requirements, risks, and deliverables.
- Proficiency in project management and productivity tools including MS Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook.
- Experience with audit readiness, quality monitoring, and regulatory compliance.
- Six Sigma certification is preferred.
Responsibilities
- Manage and prioritize operational programs and projects supporting Clinical Appeals and Utilization Management.
- Lead project planning, workflow development, stakeholder engagement, and post-implementation support.
- Partner with market leadership on new market implementations, product changes, and operational readiness.
- Collaborate with Training and Auditing teams on audit tools, quality monitoring, and remediation planning.
- Track regulatory and contractual requirements to update policies and documentation.
- Analyze Utilization Management and appeals data to investigate discrepancies and implement corrective actions.
- Represent Clinical Appeals and Utilization Management in governance and cross-functional working groups.
- Coordinate vendor-related operational activities including onboarding and performance monitoring.
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