Job Overview:

Lead a high-performing clinical operations team supporting a major US managed care program. Drive service excellence, clinical quality, and team development in a fast-paced, metrics-driven environment.

Key Responsibilities:

1) Own daily SLA/KPI performance, including turnaround time, quality, productivity, and documentation.
2) Conduct team huddles, interval monitoring, root cause analysis (RCA), and performance recovery planning.
4) Ensure strict compliance with HIPAA and PHI requirements.
5) Lead clinical quality assurance through audits, calibrations, coaching, and documentation reviews.
6) Develop and mentor registered nurses (RNs), clinical associates, and team leaders.
7) Manage competency programs, preceptorship, continuing education (CE) tracking, and license validity.
8) Collaborate with Workforce Management (WFM), Talent Acquisition (TA), Quality Assurance (QA), and client stakeholders.
9) Translate clinical protocol updates into practical workflows and training materials.

Qualifications:

1) Bachelor of Science in Nursing (BSN) graduate with an active Philippine RN license.
2) Active, unrestricted USRN license (NCLEX passed).
3) At least 5 years of clinical and healthcare operations experience.
4) At least 3 years of team leadership experience in healthcare BPO or shared services.
5) Strong knowledge of US managed care, Utilization Management (UM), Case Management (CM), CMS, and HIPAA.
6) Proven experience managing SLAs, KPIs, and clinical operational performance.
7) Background in Utilization Review (UR)/Utilization Management (UM), with current experience managing UR operations.
8) Experience in UM, CM, Health Risk Assessment (HRA), triage, or payer operations is preferred.
9) Familiarity with URAC/NCQA standards is an advantage.
10) Training experience is preferred.
11) Willing to work onsite on a US day shift.

USRN License Validity: The license must be active. Candidates whose licenses are nearing expiration must be willing to renew it.

Required Assessment:
1) Candidates must complete an on-the-spot clinical review writing assessment during the interview.
2) Please advise candidates in advance that a laptop or desktop computer is required to complete the assessment.

Recruitment Process:

1) Profile Validation
2) Profile Review
3) Talent Acquisition (TA) Interview
4) Hiring Manager (HM) Interview
5) Client Interview

Pre-Screening Notes

1. Educational Attainment:
2. Years of Clinical and Healthcare Operations Experience:
3. Years of Leadership Experience in Healthcare BPO/Shared Services:
4. UR/UM Background:** Do you have experience in Utilization Review (UR) and Utilization Management (UM)? Please provide details.
5. Licenses:** Do you have an active Philippine RN (PHRN) license and an active, unrestricted USRN license? When do your licenses expire?
6. Training Experience:** How many years of experience do you have in clinical training or education?
7. Last Drawn Salary:
8. Expected Salary: