Objectives: The Manager of Clinical Operations oversees and coordinates the operations the Musculoskeletal Management (MSM) Programs in the Care Management Unit and works collaboratively with the Vice President of Clinical Operations to facilitate the clinical certification processes.
Responsibilities (include but are not limited to):• Oversees the Clinical Reviewers and the Supervisors in the facilitation of the processing of clinical certification requests from physician offices and/or imaging centers by the Clinical Reviewers in accordance with contractual obligations and industry standards• Maintains knowledge of CareCore policies and procedures and criteria related to clinical certification• Monitors CMU team to assure that utilization management criteria are effectively and objectively utilized for the accurate determination of medical necessity and ensure clinical certification services are compliant with CareCore, URAC, NCQA, and contractually defined standards• Maintains data necessary to manage the CMU Clinical Review staff, including statistical reporting, quality audits and inter-rater testing results• Documents and reports clinical review activities to the appropriate CareCore Committees.• Conducts at minimum quarterly staff meetings with all Clinical Reviewers in the reporting area• Documents and reports follow-up of concerns and complaints regarding Clinical Review• Assists in the development and implementation of the annual QM and UM plan and yearly evaluation of clinical manuals• Actively participates in all activities related to accreditation, i.e. URAC, NCQA• Coordinates completion of performance evaluations for CMU team members and completes performance evaluations for Clinical Auditors and Supervisors• Assists in completion of quarterly audit reporting of Clinical Reviewer activity• Maintains the confidentiality of patient information in accordance with HIPPA and other regulatory requirements• Provides the lead in motivating Supervisors and team members in CMU to perform at the highest level possible and provide quality customer service• Participates in special projects to ensure that Clinical Reviewers in all locations are providing the highest level of performance and customer service
