[Remote] Clinical Operations Manager (33121)

Note: The job is a remote job and is open to candidates in USA. ExamWorks is seeking a Clinical Operations Manager to lead a remote team and provide clinical leadership across utilization management and No-Fault (PIP) programs. The role focuses on ensuring compliant, high-quality service delivery, improving workflows and clinical programs, and partnering with operational leaders, physicians, and clinical experts to support client and patient outcomes.

Responsibilities

• Oversee departmental operations to ensure services are delivered effectively and in compliance with all regulatory requirements, company policies, and HIPAA standards
• Ensure daily workflow is managed efficiently and adjust as necessary to achieve quality, productivity, and service goals
• Maintain control of operating expenses and resources to support departmental and organizational objectives
• Create and provide support, training, tools, and resources to assist staff in achieving departmental excellence and maintaining company standards
• Review and analyze quality assurance and performance data and implement improvement strategies to enhance quality, consistency, and productivity
• Serve as the department's clinical subject matter expert regarding treatment trends, industry best practices, and regulatory requirements
• Maintain knowledge of New Jersey AICRA and Michigan PIP regulations and ensure operational processes align with applicable requirements
• Collaborate with physician panel members and consulting clinical resources to support quality initiatives, clinical consistency, and program development
• Monitor clinical and treatment trends and recommend process improvements and operational enhancements
• Oversee and assist, as needed, with the resolution of provider appeals and escalated clinical issues
• Organize and participate in staff meetings and promote effective communication across all lines of business
• Respond promptly to customer service needs and resolve complex customer service situations
• Ensure staff receives timely communication regarding client-specific requirements, operational changes, and special instructions
• Ensure organizational activities and operations comply with applicable local, state, and federal laws and regulations
• Perform other duties as assigned

Skills

• Experience within the PIP, No-Fault, Workers' Compensation, or managed care industry
• Prior leadership or management experience
• A track record of developing or improving operational processes and clinical programs
• Strong knowledge of utilization review and regulatory compliance
• The ability to collaborate across teams and influence positive change
• Minimum of six years related clinical experience, including at least three years of leadership or management experience; or equivalent combination of education and experience
• Active unencumbered Registered Nursing license required
• Must possess strong knowledge of medical terminology, anatomy and physiology, medications, laboratory values, and evidence-based treatment practices
• Must possess general knowledge of automobile claims regulations as they relate to No-Fault (PIP) programs and utilization review practices
• Must possess working knowledge of nationally recognized treatment guidelines and evidence-based clinical review resources utilized in utilization review operations
• Must possess a working knowledge of medical records, health information principles, and medical-legal documentation
• Must possess strong analytical skills and the ability to evaluate operational, quality, and productivity data to support departmental goals and performance outcomes
• Must demonstrate strong critical thinking, clinical judgment, and decision-making abilities
• Ability to follow instructions and respond appropriately to management direction
• Must be proficient in Microsoft Word, Outlook, Excel, Internet applications, and other business-related software programs
• Must possess excellent verbal, written, and interpersonal communication skills
• Must be able to effectively communicate and collaborate with physicians, healthcare providers, clients, and internal stakeholders
• Must demonstrate accuracy, thoroughness, accountability, and a commitment to quality while identifying opportunities for continuous improvement
• Must exercise sound judgment, make informed decisions, and appropriately involve others in the decision-making process
• Must be able to work independently, prioritize responsibilities, and manage multiple competing priorities
• Must possess strong analytical and problem-solving skills, including the ability to evaluate clinical, operational, and quality-related information and implement effective solutions
• Must maintain confidentiality and handle sensitive information appropriately
• Must be able to foster and promote a positive, team-oriented work environment
• Must be able to remain focused and productive in a fast-paced environment with frequent interruptions
• Must be able to perform effectively under pressure and meet established deadlines
• Must be able to adapt to changing priorities, manage change effectively, and respond appropriately to unexpected situations
• Bachelor's degree in nursing, business management, healthcare administration, or related field preferred
• Experience in utilization review, clinical operations, and insurance-related healthcare services preferred
• Knowledge of the insurance industry and no-fault (PIP), workers' compensation, liability, and disability claims environments preferred
• Detailed knowledge of New Jersey AICRA and Michigan PIP regulations is preferred

Benefits

• 100% fully remote
• Medical, vision, and dental benefits
• Paid time off
• 401k

Company Overview