Hi, we’re Gravie. Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use. Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way. A Little More About the Role:We are seeking an experienced Clinical Operations Manager with deep expertise in Health Plan Operations, cost containment, and clinical strategy. You’ll take what we’re doing - creating a health plan people will love – and play a crucial leadership role in shaping our health plan’s operational and clinical policies, ensuring alignment with industry standards while driving innovative solutions. This role will require a strategic mindset, extensive experience in utilization management, plan language to claims processing, and the ability to influence cross-functional teams to optimize member care and cost efficiencies. You’ll work directly with our Clinical Services, Claims, Stop Loss, Gravie Care, Compliance, external partners including contracted networks, and Reporting teams to create SOPs and help others make equitable decisions.
You Will:●      Serve as a strategic clinical leader bridging the clinical team and health plan operations to optimize care delivery and benefit application.●      Lead the design and implementation of clinical protocols, policies, and SOPs, ensuring evidence-based practices are embedded into health plan operations.●      Monitor, evaluate, and coordinate options to facilitate appropriate benefits for members.●      Evaluate treatment plans, utilization management (UM), and prior authorization (PA) strategies, aligning them with cost containment goals while ensuring optimal member outcomes.●      Oversee policy development and standardization, driving consistency across operations.●      Provide expert guidance on Transition of Care, Continuity of Care, Medical Necessity Reviews, Appeals, and Claims Evaluations to improve efficiencies.●      Partner with network UM/CM vendors to enhance accuracy and reduce administrative errors for improved provider and member experiences.●      Support Fraud, Waste, and Abuse detection efforts, conducting internal audits and developing policies to mitigate risks.●      Identify and implement cost containment strategies, leveraging data analytics to assess trends and recommend improvements.●      Influence plan language to enhance clarity, accessibility, and member satisfaction.●      Synthesize and analyze data in collaboration with Clinical Analytics and Reporting teams, generating insights to drive continuous improvement initiatives.●      Act as a trusted clinical advisor across the organization, supporting executive decision-making with data-driven recommendations.
You Bring:●      Bachelor’s degree in Nursing; Master’s degree in Healthcare Administration, Public Health, or related field preferred.●      Unrestricted, Active RN or NP license in the state hired.●      10+ years of nursing experience, with a significant focus on health plan operations, utilization management, or strategic clinical roles.●      3+ years experiencein a leadership role, preferably within a health plan, third-party administrator (TPA), or managed care organization.●      Expertise in medical policy development, UM strategy, and regulatory compliance.●      Demonstrated experience in cost containment, claims analysis, and fraud prevention methodologies.●      Exceptional communication, leadership, and cross-functional collaboration skills.●      Strong analytical mindset with the ability to leverage data for strategic decision-making.●      Ability to work independently, manage multiple priorities, and drive impactful change.●      Demonstrated customer service, communication, and organizational skills.●      Ability to work independently, prioritize effectively, and make sound decisions. Gravie:In order to transform health insurance and build a health plan everyone can love, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an above average total rewards package. The salary range for this position is $104,332 - $175,554 annually. Numerous factors including, but not limited to, educations, skills, work experience, certifications, etc. will be considered when determining compensation. Stock options may also be awarded as part of the compensation package. Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, flexible PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, cell phone reimbursement, transportation perks, education reimbursement, and 1 week of paid paw-ternity leave. A Little More About Us:·     We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space.·     We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized.·     Our customers like us. Our revenue churn is in the low single digits, in an industry where greater than 20% churn is common.·     Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve. We may not be the right place for everybody, but if you get energized by doing work every day that focuses on putting consumers at the front of the line, we could be a great place for you. It takes unique people and diverse perspectives to deliver our results. We encourage you to be your authentic self – we like you that way.