The RoleWe are seeking a dynamic leader to join our team as the Manager, Clinical Review. This role directs the utilization review clinical team operations for our Commercial plans. The manager will lead a clinical team, foster a culture of excellence, and ensure delivery of medically necessary, high-quality, and cost-effective care. This position is accountable for maintaining rigorous compliance with all regulatory and accreditation standards while driving strategic initiatives to improve member outcomes.
Key ResponsibilitiesStrategic & Team Leadership- Provide decisive leadership and direct supervision to a clinical staff team.
- Execute a forward-thinking utilization management strategy that aligns with the company's goals.
- Lead performance management, including hiring, professional development, mentorship, and performance evaluations to build a high-performing, engaged team.
- Foster a culture of clinical excellence, empathy, and member-centered care.
Clinical Operations & Quality Assurance- Direct all utilization review functions, including pre-service, concurrent, and retrospective reviews, ensuring timeliness and adherence to evidence-based medical necessity criteria and internal medical policies.
- Ensure the utilization management program maintains robust compliance with NCQA accreditation and other federal and state regulations.
- Serve as the primary liaison between clinical teams, physician reviewers, and external organizations to resolve complex cases and clinical process issues
Data-Driven Performance Improvement- Analyze complex utilization data to identify trends, patterns, and opportunities for clinical quality improvement.
- Drive process improvement and identify opportunities to increase staff productivity and operational efficiency.
Qualifications- Education: A bachelor's degree in nursing or related clinical field is required. A master's degree in healthcare administration, Public Health, Nursing, or a related clinical field is strongly preferred.
- Licensure: Must possess an active, unrestricted clinical license in Nursing or related clinical field (e.g., RN, NP, PA, etc.). Must have the ability to secure equivalent licensure within the State of Massachusetts within 6 months of hire date.
- Experience:
- A minimum of 5-7 years of professional experience and progressive leadership in utilization management within a health plan or health system setting preferred.
- Proven experience overseeing utilization review in a managed care organization is highly desirable.
Minimum Education Requirements:High school degree or equivalent required unless otherwise noted above
LocationHingham
Time TypeFull time
Salary Range: $104,580.00 - $127,820.00
The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
