Clinical Operations Specialist
Job Location:
Somerville, NJ - USA
Monthly Salary:
Posted on:
Vacancies:
Job Summary
Mass General Brigham relies on a wide range of professionals including doctors nurses business people tech experts researchers and systems analysts to advance our mission. As a not-for-profit we support patient care research teaching and community service striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.
Job Summary
Mass General Brigham Health Plan is an exciting place to be within the healthcare industry. As a member of Mass General Brigham we are at the forefront of transformation with one of the worlds leading integrated healthcare systems. Together we are providing our members with innovative solutions centered on their health needs to expand access to seamless and affordable care and coverage.Our work centers on creating an exceptional member experience a commitment that starts with our employees. Working with some of the most accomplished professionals in healthcare today our employees have opportunities to learn and contribute expertise within a welcoming and supportive environment that embraces their unique and varied backgrounds experiences and skills.
We are pleased to offer competitive salaries and a benefits package with flexible work options career growth opportunities and much more.
The Clinical Operations Specialist oversees daily operational workflows within the Medical Director Department to ensure medical review decisions are timely compliant and consistent. This role acts as a critical bridge between clinical decision-making and administrative execution driving operational efficiency by managing high-volume workflows that support the Medical Director teams strategic goals.
The Clinical Operations Specialist is responsible for spearheading process improvement initiatives fostering cross-departmental collaboration and managing the administrative frameworks essential for Utilization Management appeals and quality compliance. Working closely with Medical Directors and cross-functional partners in Network Management Provider Relations Claims and Customer Service the Specialist resolves complex and escalated cases while strictly monitoring regulatory standards Turnaround Time (TAT) and compliance requirements. Troubleshoots the end-to-end UM process and coordinates changes with the training area.
Key Roles and Responsibilities
-Manages daily case volume in the physician queues and facilitates case assignment as needed in accordance with TAT and regulatory requirements.
-Collaborates with data analytics and quality to monitor Medical Director review volumes and quality metrics including inter-rater reliability.
-Works with the Medical Directors to collect quality concerns regarding cases sent to the unit.
-Identify bottlenecks in the clinical review lifecycle and implement lean strategies to reduce turnaround times and administrative functions.
-Optimizes physician unit operations by leading workflow design ensuring regulatory compliance and embedding changes through standardized documentation and training.
-Attends and facilitates cross-functional area case discussion with the Deputy Chief Medical Officer Senior Medical Director and other clinical leadership.
-Responsible for keeping schedules of MDs and assuring coverage and coordinating the vacation process.
-Collaborates cross-functionally with Utilization Management Network Management Provider Relations and Customer Service to resolve complex cases and escalate provider or contract issues.
-Performs other duties as assigned
-Complies with all policies and standards
Qualifications
Education
- Bachelors Degree required
Experience
- At least 2-3 years of experience working in a health plan environment required but preferably in Utilization Management
- Strong understanding of utilization management workflows including physician reviews prior authorization processes appeals peer reviews and out-of-network (OON) reviews required
- Clinical background with patient care experience preferred
- Process improvement experience preferred
Knowledge Skills and Abilities
- Strong analytical and critical thinking skills with the ability to interpret clinical data and guidelines.
- Excellent communication and interpersonal skills adept at communicating with professionals from many different backgrounds and disciplines.
- Proficiency in healthcare software systems and the Microsoft Office suite.
- Detail-oriented and organized with strong problem-solving skills.
- Committed to patient-centered care and continuous quality improvement.
- Demonstrated ability to work effectively with Medical Directors physicians and senior clinical leaders.
Additional Job Details (if applicable)
- This is a remote role that can be done from most US states
- Remote workdays require a stable secure quiet and compliant workspace
- This is a Monday through Friday 8:30 AM - 5:00 PM ET schedule
Remote Type
Work Location
Scheduled Weekly Hours
Employee Type
Work Shift
Pay Range
$99465.60 - $141804.00/AnnualGrade
8EEO Statement:
Mass General Brigham Competency Framework
At Mass General Brigham our competency framework defines what effective leadership looks like by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance make hiring decisions identify development needs mobilize employees across our system and establish a strong talent pipeline.
Required Experience:
IC
About Company
Patients at Mass General have access to a vast network of physicians, nearly all of whom are Harvard Medical School faculty and many of whom are leaders within their fields.
