Senior Clinical Consultant using extensive medical expertise for reviewing claims and assessing treatment costs in a hybrid work environment. Collaborating with internal and external teams on various healthcare solutions.
About the role
- Risk Manager overseeing and optimizing provider network performance with emphasis on dispute resolution in workers' compensation. Collaborating with internal and external stakeholders to improve outcomes.
Responsibilities
- Develop and enforce network policies and workflows to provider reimbursement disputes related to PPO discounts, provider contracts, and post-bill review reductions.
- Analyze provider appeals and adjustments to identify trends and root causes, recommending data-driven improvements.
- Collaborate with legal, clinical, and compliance teams to resolve provider disputes efficiently and consistently.
- Promote proactive communication with providers to enhance understanding of reimbursement processes and reduce conflict.
- Design and maintain network performance dashboards tracking metrics.
- Collaborate with analytics teams to evaluate network quality, effectiveness, and impact on claims outcomes.
- Own the lifecycle of network-related solutions that enhance compliance, savings, and stakeholder satisfaction.
- Translate client requirements and regulatory changes into actionable product improvements.
- Monitor market and regulatory trends to guide product innovation and maintain competitive advantage.
- Serve as the subject matter expert on network products, provider performance, and dispute processes.
- Partner with internal teams— including sales, account management, RFPs, and product launches.
- Collaborate with external vendors and partners
Requirements
- 7-10 years of experience in Network Management and or Group Health
- Experience working in or with Bill Review disciplines
- Strong written and verbal communications
- Experience working in a matrixed organization and effective with multi-stakeholder management
- Excellent relationship management and issue resolution skills
- Enjoys managing talent at all levels; familiarity working with offshore teams a plus
- Proven experience in vendor management
- Excellent organizational, analytical, and communication skills.
Benefits
- Possibility for remote and hybrid work opportunities
- Great work-life balance
- Medical, Dental and Vision insurance
- Company paid Life & Disability Insurance
- Flexible Spending Accounts
- 401(k) with employer contribution
- Generous Paid Time-Off policies
- Employee Assistance Program
- Referral Program
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