Manager of Carrier Engagement
On-site · Plano, Texas, United States
Job Summary
Manager of Carrier Engagement leads clinical-to-operations alignment for carrier reimbursements, overseeing data analytics, claims review, and process improvement. Responsible for providing clinical expertise to support workflows, reviewing claims data and medical records for billing accuracy and coding adherence (including NCCI guidelines), mentoring Clinical Analysts, designing/ refining clinical processes, developing dashboards/reports, and collaborating with IT and cross-functional teams to drive performance, cost efficiency, and service quality. Requires active clinical license or relevant credential, a Bachelor's degree, and 5+ years in clinical operations or similar healthcare roles. Strong leadership, analytical, and communication skills are essential; experience with Excel/Power BI and EMR tools is a plus.
Required Qualifications
- Active clinical license (RN, LPN/LVN or other relevant credential) preferred or inactive license with relative clinical experience or relative clinical data experience
- Bachelor’s degree in Nursing, Healthcare Administration, Business, or related field; advanced degree a plus
- 5+ years of experience in clinical operations, utilization management, case management, quality, or a related healthcare role
- Preferred- experience reviewing medical records and/or claims data from a payor perspective (preferably in a medical insurance carrier setting)
- Experience working in a cross-functional business environment strongly preferred
- Experience as a people leader/managing a team
- Strong clinical judgment with the ability to apply guidelines and standards consistently
- Analytical mindset with experience interpreting clinical and operational data
- Excellent communication and relationship-building skills
- Strong organizational and project-management abilities
- Ability to navigate complex issues with professionalism, empathy, and accountability
- Proficiency with EMR systems, clinical documentation tools, or workflow platforms is a plus
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