Associate Manager, Clinical Review Nurse (Remote)

It takes great medical minds to create powerful solutions that solve some of healthcare’s most complex challenges. Join us and put your expertise to work in ways you never imagined possible. We know you’ve honed your career in a fast-moving medical environment. While Gainwell operates with a sense of urgency, you’ll have the opportunity to work more flexible hours. And working at Gainwell carries its rewards. You’ll have an incredible opportunity to grow your career in a company that values work-life balance, continuous learning, and career development.

Summary

We are seeking a talented individual for an Associate Manager, Clinical Claim Review who is responsible for supervising the day-to-day prepay, post-pay, and utilization review activities of a multidisciplinary team of Coders, Clinical DRG Auditors, and Nurse Reviewers.  Oversees and manages the daily operations of the team by leading, assigning work, ensuring productivity and quality metrics are achieved, and analyzing production and workflow/processes to increase efficiency and quality.  Consistently demonstrates effective change management by communicating changes timely and effectively; building commitment and overcoming resistance; preparing and supporting those affected by change; monitoring transition and evaluating results.

Your role in our mission

• Responsible for oversight and hiring of staff, retaining top talent, performance management, coordinating training and education, and providing leadership and mentorship to staff to build and improve skills to provide best-in-class practices to enhance efficiency, quality, and customer satisfaction.
• Monitor aging inventory, workload, assignments, productivity, and quality to ensure service level agreements, contract deliverables, and timelines are met.
• Evaluate and analyze productivity, utilization, efficiency, finding rates, savings, appeal overturn rate, and reviews completed by staff to identify opportunities for process improvements.
• Serve as a Subject Matter Expert to assess new tools, automation, product development, and clinical readiness; act as a resource for resolving escalated issues, and coach and mentor staff to develop a high-performing team
• Analyze reports and data and identify trends and resources that improve the delivery of clinical review services.
• Manage and evaluate individual/team performance and take appropriate action to meet and/or exceed performance standards.

 What we’re looking for

• Working knowledge of the application of current official coding guidelines and coding clinic citations
• Demonstrates a thorough understanding of the APR-DRG, MS-DRG, ICD-10, clinical criteria, and clinical review judgment.
• Bachelor’s degree in business, healthcare administration, or related field preferred
• Unrestricted RN license or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) preferred
• 10+ year’s healthcare experience with 7+ years' experience in healthcare/insurance with increasing responsibility required
• 2+