Manager of Carrier Engagement
Share
Job Location:
Monthly Salary:
Posted on:
15 hours ago
Vacancies:
1 Vacancy
Job Summary
Position Overview:
TheManager of CarrierEngagement servesas the bridge between clinicalexpertiseand business operations. This role evaluatespayment integrityprocesses as it relates to carrier reimbursements supports operational decisionmaking ensures quality and compliance and partners with internal and external stakeholders to improve outcomes efficiency and experience. TheManager of CarrierEngagement usesclinical knowledge data insights and process thinking to guide program strategy resolve escalations and support continuous improvement across the thisrole leadsmanagesandmentorsthe departments Clinical Analysts.
Responsibilities
Provide clinicalexpertiseto supportoperational workflowsincluding reviewing claims data medical records
Review medical records for billing accuracy and coding guidelines
Haveexperience reviewing both facility and provider claims
Understand and apply NCCI guidelinesand be able to recognizecommon claimserrors
Reviewclinical documentation guidelines and cases to ensure accuracy compliance and alignment with standards
Managing carrier engagement clinical analyst
Partner with crossfunctional teams to design and refine clinical processes that improve outcomes and efficiency
Monitor clinical quality metrics andidentifytrends gaps and opportunities for improvement
Prepare carrier responses on open and active referrals
Lead carrier calls referral calls with carrier network and clients
Maintainaccuraterecords of clinical policies workflows and quality initiatives
Lead manage and mentor the departmentsClinicalAnalyst(s)
Collaborate with IT and serve as the liaison on business and reporting requirements for departmental IT initiatives
Translate clinical insights into operational recommendations that improve performance cost efficiency and service quality
Collaborate with Operations Payment Integrity and other teams to resolve escalations
Support the development of SOPs training materials and process improvements
Analyze clinical and operational data toidentifypatterns risks and opportunities
Develop andmaintaindashboards reports and performance summaries for leadership
Serve as a clinical subjectmatter expert for internal teams carriers partners and vendors
Provide clear empathetic communication to support escalations case reviews and program updates
Participate in crossfunctional meetings business reviews and strategic planning sessions
Develop and deliver training for internal teams on clinical guidelines workflows and quality expectations
Support onboarding of new team members by providing clinical context and program knowledge
Ensure teams understand clinical requirements thatimpactoperations payments or partner experience
Qualifications
Active clinical license (RN LPN/LVN or other relevant credential) preferredor inactive license with relative clinical experience
Bachelors degree in Nursing Healthcare Administration Business or related field; advanced degree a plus
5 years of experience in clinical operationsutilizationmanagement case management quality or a related healthcare role
Preferred- experience reviewing medical records and/or claims datafrom a payor perspective (preferably in a medical insurance carrier setting)
Experience working in a crossfunctional business environment strongly preferred
Experience as a people leader/managing a team
Skills & Competencies
Strong clinical judgment with the ability to apply guidelines and standards consistently
Analytical mindset with experience interpreting clinical and operational data
Excellent communication and relationshipbuilding skills
Strong organizational and projectmanagement abilities
Ability to navigate complex issues with professionalism empathy and accountability
Proficiencywith EMR systems clinical documentation tools or workflow platforms is a plus
Success Indicators
High accuracy and consistency in clinical reviews and documentation
Improved quality metrics and reduced clinicalrelated escalations
Strong crossfunctional alignment between clinical and business teams
Clear effective communication that supports partners and internal stakeholders
Scalable clinical processes that support operational growth and efficiency
Who isSmartLightAnalytics
SmartLightAnalytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mindSmartLightworks for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.
Required Experience:
Manager
Key Skills
- Business Development
- Employee Orientation
- Public Health
- Account Management
- VersionOne
- Conflict Management
- Project Management
- Relationship Management
- Team Management
- Customer relationship management
- Human Resources
- Public Speaking
About Company
Harness the power of your healthcare data Solutions to lower healthcare costs without interrupting benefits Learn More DATA LEADS THE WAY SmartLight Analytics provides independent, ongoing monitoring of your employee healthcare claims data to find and remove wasteful spend from your h ... View more
