Clinical Care Manager

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation’s leading not-for-profit Medicare Advantage plans, serving more than 285,000 members in California, Arizona, Nevada, and Texas. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare

Provides clinical oversight and ensures the efficient handling of member appeals and grievances, maintaining compliance with Medicare regulations and company policies. This role leads a team of clinical and support staff, ensuring high-quality care and member satisfaction.

Lead and manage a team of clinical and support staff, providing clinical guidance, training, and performance evaluations. Foster a positive and collaborative work environment that promotes teamwork and continuous improvement. Provide clinical oversight for all appeals and grievances, ensuring medical decisions are based on sound clinical judgment and evidence-based practices. Review and approve clinical documentation and decisions to ensure accuracy and compliance with regulatory standards. Develop and maintain departmental policies and procedures to ensure compliance with Medicare regulations and company standards. Regularly review and update policies to reflect changes in regulations and best practices. Oversee the intake, review, and resolution of member appeals and grievances, ensuring all cases are handled in a timely and accurate manner. Collaborate with interdisciplinary teams to gather necessary clinical information and make informed decisions. Implement and monitor quality assurance processes to ensure all appeals and grievances are handled according to established clinical standards. Conduct regular audits and reviews to identify areas for improvement and implement corrective actions. Maintain open lines of communication with members, healthcare providers, and internal stakeholders. Prepare and present reports on departmental activities, outcomes, and performance metrics to senior management. Ensure all departmental activities comply with Medicare regulations, state laws, and company policies. Stay informed about changes in regulations and industry standards and adjust departmental practices accordingly. Advocate for members to ensure their clinical concerns are addressed and their rights are protected. Provide clear and compassionate communication to members throughout the appeals and grievance process. Develop and deliver training programs to ensure staff are knowledgeable about Medicare regulations, company policies, and best clinical practices. Encourage and support professional development opportunities for team members. Build and maintain strong relationships with healthcare providers, payers, and other stakeholders to facilitate smooth and effective resolution of appeals and grievances. Participate in cross-departmental initiatives to enhance overall member care and satisfaction. All other duties as assigned.