Clinical Operations Manager - Registered Nurse (RN) (Remote U.S.)

CNSI and Kepro are now Acentra Health! Acentra Health exists to empower better health outcomes through technology, services, and clinical expertise. Our mission is to innovate health solutions that deliver maximum value and impact.

Lead the Way is our rallying cry at Acentra Health. Think of it as an open invitation to embrace the company’s mission, actively engage in problem-solving, and take ownership of your work daily. Acentra Health offers you unparalleled opportunities. In fact, you have all you need to take charge of your career and accelerate better outcomes – making this a great time to join our team of passionate individuals dedicated to being a vital partner for health solutions in the public sector.

Acentra seeks a Clinical Operations Manager – Registered Nurse (RN) (Remote U.S.) to join our growing team.

Job Summary:

The Clinical Operations Manager - Registered Nurse (RN) is responsible for:

• Providing firsthand operational expertise and leadership to the company’s utilization management Indiana contract.
• Acting as a strategic partner to the Program Director in the innovation, design, and implementation of new strategies to continue to improve operations and clinical services.
• Collaboratively enhancing utilization management capabilities and execution through the development of strong management relationships with other areas within and outside the organization.
• Providing day-to-day oversight of the Clinical Review team.

** This is a full-time, remote-based, direct-hire opportunity with Benefits. **

Job Responsibilities:

• Provide day-to-day oversight of Supervisors of UM activities to ensure utilization review activities are conducted timely meeting IAC and URAC regulatory standards.
• Build a high-functioning team that meets all operating goals, including quality, efficacy, and cost of health care, administrative expense, customer service, performance improvement, regulatory requirement satisfaction, and staff engagement.
• Direct and evaluate the activities and effectiveness of Utilization Management activities.
• Provide clinical support and education as necessary to all UM staff.
• Serve as the Subject Matter expert for all Case Types.
• Ensure regular departmental staff meetings are conducted and action items and follow-up issues are completed.
• Partner with other Departments to develop, implement, and monitor system-wide performance improvement initiatives for Utilization Management measures.
• Coordinate with other operational departments to identify and achieve workflow improvements to gain process and procedure efficiencies and create standardized reporting across all functional areas.
• Evaluate the effectiveness of utilization management through analysis of defined metrics and recommend enhancements and/or improvements to facilitate consistent, cost-effective, and proactive utilization management.
• Identify and recommend opportunities for cost savings while improving the quality of care across the continuum.
• Develop and implement robust performance and operational metrics for all processes and products, including outcome metrics for specific products.
• Identify, design, and implement Process Improvement opportunities that support utilization management operations.
• Conduct UM Reviews as needed to help the team meet contractual and regulatory turn-around times.
• Ensure compliance with contractual requirements within the clinical operation by monitoring critical indicators and adjusting processes to compensate for negative variances.
• Assists in achieving annual organizational priorities and operational indicators.
• Foster and maintain strong communications with staff through various means, e.g., one-on-one meetings, team meetings, and interdepartmental meetings.
• Help support the clinical quality program to include auditing, Quality Improvement Plans (QIPs), and administration of the Local Quality Improvement Committee.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

Required Qualifications/Experience:

• An Associate's degree in nursing will be considered in conjunction with strong utilization management leadership experience in a managed care setting.
• 5+ years of Utilization Management (UM) experience with a health plan.
• Broad clinical knowledge with a good clinical background and analytical and decision-making skills.
• 5+ years of successful management experience in a managed care setting with Medicaid, Medicare, or Commercial Lines of Business.
• Experience with managed care audits and reviews.
• Experience with Quality Assessment and Process Improvement (QAPI) projects.
• Demonstrated experience with writing and implementing program-level policies and procedures.
• Experience applying medical management treatment guidelines, such as InterQual, Milliman, or other practical management guidelines.
• Ability to lead and manage significant change with a performance-driven management style.
• Ability to implement a performance matrix and outcomes matrix.
• In-depth knowledge of all aspects of managed care medical management, including UM/CM, Grievance and Appeals, medical policy, clinical claims review (professional and facility), and delegated vendor oversight.

Knowledge, Skills, Abilities

• Ability to think strategically and act tactically.
• Ability to work cross-functionally and collaboratively across the leadership team.
• Strong leadership skills are a prerequisite, including excellent interpersonal, communication, problem-solving, and negotiating skills.
• Experience in using systems that support Utilization processing.
• Demonstrated expertise in managing differing customer needs.
• Understanding of Utilization Review Accreditation Commission (URAC) standards and processes.
• Ability to participate as a team member, fostering collaborative decision-making among leadership, committees, teams, or work groups of diverse composition.
• Computer proficiency in Microsoft Office applications and other software programs essential to performing job functions.
• Ability to develop, plan, and implement short-and long-range goals.
• Skilled in employee development and performance management.
• Ability to provide technical guidance and leadership to the management team.
• Advanced verbal and written communication skills and the ability to work with a wide range of constituencies in a diverse community.

Why us?

We are a team of experienced and caring leaders, clinicians, pioneering technologists, and industry professionals who come together to redefine expectations for the healthcare industry. State and federal healthcare agencies, providers, and employers turn to us as their vital partner to ensure better healthcare and improve health outcomes.

We do this through our people.

You will have meaningful work that genuinely improves people's lives nationwide. Our company cares about our employees, giving you the tools and encouragement, you need to achieve the finest work of your career.

Benefits are a key component of your rewards package. Our benefits are designed to provide additional protection, security, and support for your career and life away from work. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts, and more.  

Compensation

The pay range for this position is $100,000-110,000 annually.

“Based on our compensation philosophy, an applicant’s placement in the pay range will depend on various considerations, such as years of applicable experience and skill level.”

Thank You!

We know your time is valuable, and we thank you for applying for this position. Due to the high volume of applicants, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Acentra Health and invite you to apply to future openings that may interest you. Best of luck in your search!

~ The Acentra Health Talent Acquisition Team

Visit us at Acentra.com/careers/

EOE AA M/F/Vet/Disability

Acentra Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by applicable Federal, State, or Local law.

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