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Clinical Operations Manager
GravieUKRemotefull_timeVerifiedPosted 26 Feb 2025
💰 $175,554/yr($104,332/yr – $175,554/yr)
About the role
Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way. A Little More About the Role:We are seeking an experienced Clinical Operations Manager with deep expertise in Health Plan Operations, cost containment, and clinical strategy. You’ll take what we’re doing - creating a health plan people will love – and play a crucial leadership role in shaping our health plan’s operational and clinical policies, ensuring alignment with industry standards while driving innovative solutions. This role will require a strategic mindset, extensive experience in utilization management, plan language to claims processing, and the ability to influence cross-functional teams to optimize member care and cost efficiencies. You’ll work directly with our Clinical Services, Claims, Stop Loss, Gravie Care, Compliance, external partners including contracted networks, and Reporting teams to create SOPs and help others make equitable decisions.
You Will:● Serve as a strategic clinical leader bridging the clinical team and health plan operations to optimize care delivery and benefit application.● Lead the design and implementation of clinical protocols, policies, and SOPs, ensuring evidence-based practices are embedded into health plan operations.● Monitor, evaluate, and coordinate options to facilitate appropriate benefits for members.● Evaluate treatment plans, utilization management (UM), and prior authorization (PA) strategies, aligning them with cost containment goals while ensuring optimal member outcomes.● Oversee policy development and standardization, driving consistency across operations.● Provide expert guidance on Transition of Care, Continuity of Care, Medical Necessity Reviews, Appeals, and Claims Evaluations to improve efficiencies.● Partner with network UM/CM vendors to enhance accuracy and reduce administrative errors for improved provider and member experiences.● Support Fraud, Waste, and Abuse detection efforts, conducting internal audits and developing policies to mitigate risks.● Identify and implement cost containment strategies, leveraging data analytics to assess trends and recommend improvements.● Influence plan language to enhance clarity, accessibility, and member satisfaction.● Synthesize and analyze data in collaboration with Clinical Analytics and Reporting teams, generating insights to drive continuous improvement initiatives.● Act as a trusted clinical advisor across the organization, supporting executive decision-making with data-driven recommendations.
You Bring:● Bachelor’s degree in Nursing; Master’s degree in Healthcare Administration, Public Health, or related field preferred.● Unrestricted, Active RN or NP license in the state hired.● 10+ years of nursing experience, with a significant focus on health plan operations, utilization management, or strategic clinical roles.● 3+ years experiencein a leadership role, preferably within a health plan, third-party administrator (TPA), or managed care organization.● Expertise in medical policy development, UM strategy, and regulatory compliance.● Demonstrated experience in cost containment, claims analysis, and fraud prevention methodologies.● Exceptional communication, leadership, and cross-functional collaboration skills.● Strong analytical mindset with the ability to leverage data for strategic decision-making.● Ability to work independently, manage multiple priorities, and drive impactful change.● Demonstrated customer service, communication, and organizational skills.● Ability to work independently, prioritize effectively, and make sound decisions. Gravie:In order to transform health insurance and build a health plan everyone can love, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an
You Will:● Serve as a strategic clinical leader bridging the clinical team and health plan operations to optimize care delivery and benefit application.● Lead the design and implementation of clinical protocols, policies, and SOPs, ensuring evidence-based practices are embedded into health plan operations.● Monitor, evaluate, and coordinate options to facilitate appropriate benefits for members.● Evaluate treatment plans, utilization management (UM), and prior authorization (PA) strategies, aligning them with cost containment goals while ensuring optimal member outcomes.● Oversee policy development and standardization, driving consistency across operations.● Provide expert guidance on Transition of Care, Continuity of Care, Medical Necessity Reviews, Appeals, and Claims Evaluations to improve efficiencies.● Partner with network UM/CM vendors to enhance accuracy and reduce administrative errors for improved provider and member experiences.● Support Fraud, Waste, and Abuse detection efforts, conducting internal audits and developing policies to mitigate risks.● Identify and implement cost containment strategies, leveraging data analytics to assess trends and recommend improvements.● Influence plan language to enhance clarity, accessibility, and member satisfaction.● Synthesize and analyze data in collaboration with Clinical Analytics and Reporting teams, generating insights to drive continuous improvement initiatives.● Act as a trusted clinical advisor across the organization, supporting executive decision-making with data-driven recommendations.
You Bring:● Bachelor’s degree in Nursing; Master’s degree in Healthcare Administration, Public Health, or related field preferred.● Unrestricted, Active RN or NP license in the state hired.● 10+ years of nursing experience, with a significant focus on health plan operations, utilization management, or strategic clinical roles.● 3+ years experiencein a leadership role, preferably within a health plan, third-party administrator (TPA), or managed care organization.● Expertise in medical policy development, UM strategy, and regulatory compliance.● Demonstrated experience in cost containment, claims analysis, and fraud prevention methodologies.● Exceptional communication, leadership, and cross-functional collaboration skills.● Strong analytical mindset with the ability to leverage data for strategic decision-making.● Ability to work independently, manage multiple priorities, and drive impactful change.● Demonstrated customer service, communication, and organizational skills.● Ability to work independently, prioritize effectively, and make sound decisions. Gravie:In order to transform health insurance and build a health plan everyone can love, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an
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