Associate Manager, Clinical Claim Review- 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, Appeals and Hearings, who is responsible for supervising the day-to-day appeals and hearings activities of a multidisciplinary appeals 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

• Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC), required
• Bachelor’s degree in business, healthcare administration, or related field preferred
• 10+ year’s healthcare experience with 7+ years experience in healthcare/insurance with increasing responsibility required
• 2+ year’s management or supervisory experience preferred
• Demonstrates a thorough understanding of the APR-DRG, MS-DRG, ICD-10, clinical criteria, and clinical review judgment.

What to Expect in This Role

• Remote position within the U.S.
• Up to 20% travel required

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The pay range for this position is $80,000.00 - $105,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. Put your passion to work at Gainwell. You’ll have the opportunity to grow your career in a company that values work flexibility, learning, and career development. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities.

We believe nothing is impossible when you bring together people who care deeply about making healthcare work better for everyone. Build your career with Gainwell, an industry leader. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings.

Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics.