The Clinical Program Manager, Healthcare Review Services shall be responsible for the oversight of the Healthcare Review service line. The CPM shall be responsible for day-to-day employee, production, and client management. The CPM is responsible for ensuring operational efficiency, and accuracy; staff management and training; and quality management in the Healthcare Review (HCR) service line. The CPM shall also ensure HCR employees are proficient in their roles and receive the appropriate ongoing training; ensuring operational efficiency, and accuracy; and ensuring MMRO’s HCR products and services are consistent and meet both external and internal requirements, including URAC standards and customer expectations.

Role and Responsibilities

• Responsible for the day-to-day operational oversight, staffing, workload assignment, and overall performance of the department, specifically the clinical and administrative functions of the service line, ensuring efficient daily operations and compliance with corporate, accreditation, and client program performance standards and requirements.
• Provide guidance and direction to staff to assist with problem resolution, problem intervention, advice, and overall professional development.
• Ensure all clients are served at the highest level of satisfaction through quality service, courteous employees, and quick and accurate response to client needs.
• Participate in assigned client conference calls and/or meetings related to operational performance, client implementation, operational updates and training, client needs, and/or new service line development.
• Monitor daily production and performance including turnaround timeframes, lead times, on-time performance, and first pass-yield.
• Develop and monitor daily operational activity reports for case processing, appropriate workload assignments, productivity measures, and problem identification.
• Develop and implement training modules and training programs specific to operational processes, client programs, and corporate/client policy.
• Facilitate on-the-job training for assigned staff, as needed, or as dictated by results of employee audit, performance review, or productivity measure.
• Policy and procedure development and monitoring, consistent with client, corporate, and accreditation compliance requirements.
• Assist in staff hiring efforts, including participation in interviews, selection, and onboarding of new staff.
• Perform employee Performance Reviews for assigned staff, per corporate policy.
• Review and approve staff PTO requests, subject to Program workload demands.
• Identify departmental Quality Improvement and operational process improvement opportunities.
• Communicate with IT personnel when operational needs/assistance is identified.
• Protects confidential patient information in compliance with confidentiality and security policies.
• Other duties, as deemed appropriate.

Required Qualifications and education

• Minimum two (2) years operational management experience
• Minimum five (5) years clinical experience
• Working knowledge of health care reviews (appeals, prior authorizations, etc.)
• Working knowledge of diagnostic coding (i.e., ICD-10)
• Working knowledge of CPT coding
• Critical thinking skills
• Good decision-making skills
• Detail-oriented
• Ability to work autonomously, as well as within a team structure
• Computer literate
• Good working knowledge of MS Word and Excel
• Good telephonic speaking skills
• Ability to multi-task
• Good written and verbal skills
• Must be able to travel to onsite client meetings when attendance is required

Preferred skills and additional experience

• Registered Nurse licensure
• Prior health plan or IRO clinical experience preferred
• Bachelor’s degree in health or management-related field

Physical demands

Normal office environment.  Stressful conditions may arise when workload becomes more demanding than normal.  The physical requirements of the job are considered Sedentary Work per the U.S. Department of Labor, which is work involving the exertion of up to 10 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary Work involves sitting most of the time but may involve walking or standing for brief periods of time.

Additional Notes

When attending any internal or external virtual meetings, camera use is required.