Clinical Operations Manager

Summary

Join Gravie as a Clinical Operations Manager and play a crucial leadership role in shaping our health plan's operational and clinical policies. You will bridge the clinical team and health plan operations, lead the design and implementation of clinical protocols, and monitor member benefits. This role requires a strategic mindset, extensive experience in utilization management, and the ability to influence cross-functional teams. You will work with various teams to create SOPs and ensure equitable decisions. The ideal candidate will possess a Bachelor's degree in Nursing, an active RN or NP license, and significant experience in health plan operations and utilization management. Gravie offers a competitive salary and a unique benefits package.

Requirements

• Bachelor’s degree in Nursing
• 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 experience in 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

Responsibilities

• 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

Preferred Qualifications

Master’s degree in Healthcare Administration, Public Health, or related field

Benefits

• Opportunities for career growth
• Meaningful mission-driven work
• Above average total rewards package
• Salary range for this position is $104,332 - $175,554 annually
• Stock options may also be awarded as part of the compensation package
• Standard health and wellness benefits
• Alternative medicine coverage
• Flexible PTO
• Up to 16 weeks paid parental leave
• Paid holidays
• A 401k program
• Cell phone reimbursement
• Transportation perks
• Education reimbursement
• 1 week of paid paw-ternity leave