Clinical Operations Manager

February 27

❄️ Minnesota – Remote

Although this job is listed in Minnesota, this company may be open to hiring remote in other states.

💵 $104.3k - $175.6k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🏥 Clinical Operations

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Gravie

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Gravie is a company specializing in providing innovative health benefits and insurance solutions. Their offerings include the Comfort health plan, which simplifies health coverage with no deductibles and zero copays on common healthcare services. Gravie also provides Individual Coverage Health Reimbursement Arrangements (ICHRA) and Gravie Pay, a support system for managing healthcare costs. The company emphasizes clear and straightforward benefits that facilitate preventive care and reduce unexpected healthcare expenses, catering to both individual members and small to midsize businesses. Gravie aims to make health benefits accessible, understandable, and cost-effective for employers and employees alike.

health insurance • health care • employer benefits • health • wellness

51 - 200 employees

⚕️ Healthcare Insurance

💳 Fintech

🤝 B2B

📋 Description

• Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. • A Little More About the Role: • We are seeking an experienced Clinical Operations Manager with deep expertise in Health Plan Operations, cost containment, and clinical strategy. • You’ll take what we’re doing - creating a health plan people will love – and play a crucial leadership role in shaping our health plan’s operational and clinical policies. • Ensure alignment with industry standards while driving innovative solutions. • This role will require a strategic mindset, extensive experience in utilization management, plan language to claims processing, and the ability to influence cross-functional teams to optimize member care and cost efficiencies. • You’ll work directly with our Clinical Services, Claims, Stop Loss, Gravie Care, Compliance, external partners including contracted networks, and Reporting teams to create SOPs and help others make equitable decisions. • You Will: • 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.

🎯 Requirements

• Bachelor’s degree in Nursing; Master’s degree in Healthcare Administration, Public Health, or related field preferred. • 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.

🏖️ Benefits

• Alternative medicine coverage • Flexible PTO • Up to 16 weeks paid parental leave • Paid holidays • 401k program • Cell phone reimbursement • Transportation perks • Education reimbursement • 1 week of paid paw-ternity leave