Healthcare Clinical Operations Expert

1 week ago


New York, New York, United States EmblemHealth Full time
Job Overview

We are seeking a highly skilled Healthcare Clinical Operations Expert to join our team at EmblemHealth. In this role, you will be responsible for managing the clinical aspects of our business, including assessing medical risk for each identified claimant and applying appropriate guidelines to meet the financial risk management goals of the company.

You will review detailed large claim reports and available clinical information from various sources, including trigger reports, detailed individual claim reports, pending and denied reports, case management reports, and utilization reports.

The ideal candidate will have 4-6+ years of professional relevant work experience, with 4 years' experience in medical underwriting or medical risk management, clinical coding, or AHIP certification. A Bachelor's Degree in Nursing or related clinical field is preferred.

Key Responsibilities:

  • Develop and implement effective clinical operations strategies to improve patient outcomes and reduce costs.
  • Collaborate with internal stakeholders to ensure seamless communication and coordination of clinical services.
  • Analyze medical data and reports to identify trends and opportunities for improvement.
  • Make recommendations to senior leadership on clinical operations strategy and policy.

Estimated Salary: $80,000 - $110,000 per year, depending on experience and qualifications.


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