Job Description

Job Summary The Clinical Manager is accountable to plan, organize, manage, and evaluate clinical operations for Medical Review. They develop CMS reports and manage activities to ensure accurate rendering of claim decisions, collaborating across business areas to meet WPS and CMS goals while ensuring compliance with regulations. Salary Range $100,000 ~ $120,000. The base pay may vary within the posted range based on job-related knowledge, skills, and experience. Work Location Remote or Hybrid. Remote work is open to approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin. Employees living within 45 miles of WPS Headquarters (1717 W. Broadway, Madison, WI) will be expected to come into the office 2 days a week. Responsibilities Develop, implement, and maintain the Improper Payment Reduction Strategy (IPRS) for Medical Review. Lead monitoring and maintaining Full Time Equivalents (FTEs), budget, and workload according to IPRS. Ensure accurate and timely handling of Medical Review clinical decisions. Monitor all results for Medical Review Accuracy Award Fee, providing follow-up, dispute, and education as indicated. Coordinate with the Medical Review Operations Manager in preparation of the Monthly Status Report. Ensure effective and timely response to clinical concerns raised by CMS, other CMS contractors, and other clinical areas. Maintain detailed knowledge of all Medicare regulations and broad level knowledge of WPS business capabilities. Ensure compliance within federal and state regulations, CMS guidelines, and company policies. Coach and mentor the Clinical Med Management team to ensure a culture of accountability and excellence; execute programs to drive employee engagement and satisfaction. Minimum Qualifications Associate's (ASN) or Bachelor's Degree in Nursing (BSN). Active RN license in good standing in the state of practice. 5 or more years of clinical experience in a healthcare setting. 3 or more years in a leadership role. Extensive knowledge and understanding of CMS guidelines and regulations. Extensive knowledge and understanding of medical/clinical review processes. Strong analytical, problem‑solving, and organizational skills, including the ability to manage multiple cases simultaneously and meet strict deadlines. Excellent reading comprehension, written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely. Proficient in Microsoft Office tools with experience working in electronic health records. Preferred Qualifications Experience working for a Medicare Administrative Contractor (MAC). Remote Work Requirements Wired (ethernet cable) internet connection from router to computer. High‑speed cable or fiber internet. Minimum 10 Mbps downstream and at least 1 Mbps upstream. Review Remote Worker FAQs for additional information. Benefits Remote and hybrid work options available. Performance bonus and/or merit increase opportunities. 401(k) with 100% match for the first 3% of salary and 50% match for next 2% (100% vested immediately). Competitive paid time off. Health insurance, dental insurance, and telehealth services start Day 1. Professional and Leadership Development Programs. Review additional benefits at Regulatory & Legal Information This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data. Equal Opportunity Employer Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr

Job Tags

Similar Jobs