Clover is reinventing health insurance to keep people healthier.
Utilization Management is responsible for ensuring that patients have access to the right care at the right time, in the right setting. Our cross functional, hybrid in-house and outsourced, group of nurses, coordination support, and operations staff work together to ensure timely review and personalized clinical decision-making that supports our members in compliant with CMS regulations.
As the Operations Manager, you'll oversee and manage the non-clinical day-to-day operations of the fast-paced, highly cross-functional Utilization Management team. You'll also be responsible for managing and eliciting the best from a variety of best-in-class technological, clinical, and administrative vendors.
As an Operations Manager, you will:
- Manage a team of ~5 non-clinical UM supervisors and individual contributors.
- Manage Clover UM vendor partnerships to ensure all contract stipulations are being met, relationships are in good standing, and Clover is utilizing all available services
- Apply understanding of UM regulation to help guide the team in compliantly adjudicating complex cases and prioritizing work and establishing appropriate QA processes
- Serve as a point of escalation for issues raised by providers/vendors regarding Clover processes
- Monitor and analyze the productivity and quality of UM in-house and outsourced operations to ensure compliance with regulatory requirements with Federal, State and other regulatory bodies.
- Provide ongoing feedback and training to the staff on new processes and identified issues.
- Respond to Grievances/CTMs, Subpoenas, and inquiries from regulatory entities in regards to the operations of the department.
- Continuously improve internal UM content expertise by attending conferences on Medicare regulations and staying up to date on industry changes and trends.
- Partner with compliance, operations, and technical teams to develop and support the writing of policies and desktop procedures, make strategic business decisions, and implement new initiatives.
You will love this job if:
- You are humble and understand that as a manager of people, you are there to serve and support to ensure that every person interacting with Clover’s core, back-office operations are set up for success.
- You deeply understand people and their intrinsic motivations; you're able to drive, motivate, and guide teams towards department and company goals.
- You are a team player. You enjoy collaborating with a diverse team, and want to partner with others to leverage data for decision making and innovative new solutions.
- You have a critical and analytical mindset. You understand how all the components of a process fit together and believe in the value of making data-driven decisions; you continuously monitor the efficacy of your programs through metrics tracking.
- You are nimble, and comfortable working in a constantly evolving environment. You embrace ambiguity and speed while maintaining a bias towards action.
- You're excited by the opportunity to also support and bring structure to the professional development and growth of the members of the team.
You should get in touch if:
- You have a BS/BA degree and at least 10 years of UM experience.
- You have over 5 years of experience as a people manager.
- You've worked to continuously improve the quality and productivity of vendor partners.
- You constantly knowledge share with others and, more importantly, practice active listening.
- Eloquence is your strong suit and you can articulate complex processes and needs.
Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. We are an E-Verify company.