Clinical Operations Manager (33121)

SUMMARY

The Clinical Operations Manager is responsible for the oversight, management, and continuous improvement of the Company's clinical operations and programs. This position provides clinical leadership and subject matter expertise related to utilization management, treatment trends, regulatory requirements, and industry best practices, with a focus on automobile claims, utilization review operations, and No-Fault (PIP) programs, including New Jersey AICRA and Michigan PIP regulations.  The Clinical Operations Manager leads clinical staff, supports quality and performance initiatives, and collaborates with operational leadership, physician panel members, and consulting clinical resources to ensure the delivery of high-quality, compliant, and efficient services. The role serves as a key resource for clinical operations, provider relations, process improvement, and the development of clinical programs that support organizational objectives and client needs.

ESSENTIAL JOB FUNCTIONS

- Oversee departmental operations to ensure services are delivered effectively and in compliance with all regulatory requirements, company policies, and HIPAA standards.

- Ensure daily workflow is managed efficiently and adjust as necessary to achieve quality, productivity, and service goals.

- Maintain control of operating expenses and resources to support departmental and organizational objectives.

- Create and provide support, training, tools, and resources to assist staff in achieving departmental excellence and maintaining company standards.

- Review and analyze quality assurance and performance data and implement improvement strategies to enhance quality, consistency, and productivity.

- Serve as the department's clinical subject matter expert regarding treatment trends, industry best practices, and regulatory requirements.

- Maintain knowledge of New Jersey AICRA and Michigan PIP regulations and ensure operational processes align with applicable requirements.

- Collaborate with physician panel members and consulting clinical resources to support quality initiatives, clinical consistency, and program development.

- Monitor clinical and treatment trends and recommend process improvements and operational enhancements.

- Oversee and assist, as needed, with the resolution of provider appeals and escalated clinical issues.

- Organize and participate in staff meetings and promote effective communication across all lines of business.

- Respond promptly to customer service needs and resolve complex customer service situations.

- Ensure staff receives timely communication regarding client-specific requirements, operational changes, and special instructions.

- Ensure organizational activities and operations comply with applicable local, state, and federal laws and regulations.

- Perform other duties as assigned.

ESSENTIAL MANAGERIAL RESPONSIBILITIES

- Carry out all supervisory responsibilities in accordance with company policies, standards, and applicable employment laws.

- Manage and monitor staff workload, productivity, and performance to ensure departmental goals and service standards are achieved.

- Provide coaching, guidance, training, and development opportunities to support employee growth and success.

- Foster a positive work environment by promoting teamwork, accountability, employee engagement, and effective conflict resolution.

- Oversee employee scheduling, attendance, and timecard approval, and coordinate staffing and overtime needs as required.

- Participate in recruiting, interviewing, hiring, onboarding, and retention activities.

- Develop and implement plans to achieve departmental goals, performance metrics, and client expectations.

- Communicate organizational and departmental changes effectively and support employees through change initiatives.

- Address performance concerns through coaching, counseling, corrective action, and performance improvement plans, as appropriate.

- Conduct performance evaluations and provide ongoing feedback regarding employee performance, development, and advancement opportunities.

- Partner with leadership to identify staffing, training, and succession planning needs within the department.

Qualifications

Education and/or Experience

Bachelor degree in nursing, business management, healthcare administration, or related field preferred. Minimum of six years related clinical experience, including at least three years of leadership or management experience; or equivalent combination of education and experience. Experience in utilization review, clinical operations, and insurance-related healthcare services preferred. Knowledge of the insurance industry and no-fault (PIP), workers' compensation, liability, and disability claims environments preferred.

Certificates, Licenses, Registrations

Active unencumbered Registered Nursing license required.

QUALIFICATIONS

- Must possess strong knowledge of medical terminology, anatomy and physiology, medications, laboratory values, and evidence-based treatment practices.

- Must possess general knowledge of automobile claims regulations as they relate to No-Fault (PIP) programs and utilization review practices. Detailed knowledge of New Jersey AICRA and Michigan PIP regulations is preferred.

- Must possess working knowledge of nationally recognized treatment guidelines and evidence-based clinical review resources utilized in utilization review operations.

- Must possess a working knowledge of medical records, health information principles, and medical-legal documentation.

- Must possess strong analytical skills and the ability to evaluate operational, quality, and productivity data to support departmental goals and performance outcomes.

- Must demonstrate strong critical thinking, clinical judgment, and decision-making abilities.

- Ability to follow instructions and respond appropriately to management direction.

- Must be proficient in Microsoft Word, Outlook, Excel, Internet applications, and other business-related software programs.

- Must be able to operate standard office equipment, including computer, copier, scanner, and telephone.

- Must possess excellent verbal, written, and interpersonal communication skills.

- Must be able to effectively communicate and collaborate with physicians, healthcare providers, clients, and internal stakeholders.

- Must demonstrate accuracy, thoroughness, accountability, and a commitment to quality while identifying opportunities for continuous improvement.

- Must exercise sound judgment, make informed decisions, and appropriately involve others in the decision-making process.

- Must be able to work independently, prioritize responsibilities, and manage multiple competing priorities.

- Must possess strong analytical and problem-solving skills, including the ability to evaluate clinical, operational, and quality-related information and implement effective solutions.

- Must maintain confidentiality and handle sensitive information appropriately.

- Must be able to foster and promote a positive, team-oriented work environment.

- Must be able to remain focused and productive in a fast-paced environment with frequent interruptions.

- Must be able to perform effectively under pressure and meet established deadlines.

- Must be able to adapt to changing priorities, manage change effectively, and respond appropriately to unexpected situations.

- Ability to follow all company policies and procedures in effect at time of hire and as amended.

LANGUAGE/COMMUNICATION SKILLS

- Ability to read, analyze and interpret common correspondence, medical records, and legal contracts and documents.

- Ability to write clearly and informatively to all required audiences and edit own work for appropriate spelling and grammar.

- Ability to respond appropriately and professionally to all inquiries or complaints from customers, physicians, regulatory agencies, and/or members of the business community.

- Ability to effectively present information one-on-one or in small groups.

- Ability to communicate clinical, operational, and regulatory information in a clear and concise manner to both clinical and non-clinical audiences.

- Ability to establish and maintain effective working relationships with physicians, healthcare providers, clients, employees, and management.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position generally consists of:

- Ability to work at a desk or similar office-type furnishings up to 8 hours a day or longer as required by business needs.

- Ability to operate a computer up to 4 hours at a time.

- Occasionally lifting and/or carrying up to 10 lbs.

- Occasionally pushing/pulling up to 25 lbs.

- Occasionally subject to bending, squatting or twisting.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

- This is remote position based within the United States.

- Employee must maintain a dedicated workspace that supports productivity, confidentiality, and compliance with company policies.

- Reliable high-speed internet access is required to perform essential job functions and participate in virtual meetings and communications.

- Occasional travel may be required for meetings, training, conferences, or other business-related events.

- Extended hours may occasionally be required based on business needs.

- The noise level in the work environment is generally moderate.