Manager of Carrier Engagement

Position Overview:  The Manager of Carrier Engagement serves as the bridge between clinical expertise and business operations. This role evaluates payment integrity processes as it relates to carrier reimbursements, supports operational decision‑making, ensures quality and compliance, and partners with internal and external stakeholders to improve outcomes, efficiency, and experience. The Manager of Carrier Engagement uses clinical knowledge, data insights, and process thinking to guide program strategy, resolve escalations, and support continuous improvement across the organization.  Additionally, this role leads, manages and mentors the department’s Clinical Analysts.   Responsibilities  Provide data analytics to support client and carrier requests  Partner with internal teams to improve accuracy using data analysis and carrier feedback  Provide clinical expertise to support operational workflows including reviewing claims data medical records  Review medical records for billing accuracy and coding guidelines  Have experience reviewing both facility and provider claims  Understand and apply NCCI guidelines and be able to recognize common claims errors  Review clinical documentation, guidelines, and cases to ensure accuracy, compliance, and alignment with standards  Managing carrier engagement clinical analyst  Partner with cross‑functional teams to design and refine clinical processes that improve outcomes and efficiency  Monitor clinical quality metrics and identify trends, gaps, and opportunities for improvement  Prepare carrier responses on open and active referrals  Lead carrier calls, referral calls with carrier network and clients  Maintain accurate records of clinical policies, workflows, and quality initiatives  Lead, manage and mentor the department’s Clinical Analyst(s)  Collaborate with IT and serve as the liaison on business and reporting requirements for departmental IT initiatives  Translate clinical insights into operational recommendations that improve performance, cost efficiency, and service quality  Collaborate with Operations, Payment Integrity, and other teams to resolve escalations  Support the development of SOPs, training materials, and process improvements  Analyze clinical and operational data to identify patterns, risks, and opportunities  Develop and maintain dashboards, reports, and performance summaries for leadership  Serve as a clinical subject‑matter expert for internal teams, carriers, partners, and vendors  Provide clear, empathetic communication to support escalations, case reviews, and program updates  Participate in cross‑functional meetings, business reviews, and strategic planning sessions  Develop and deliver training for internal teams on clinical guidelines, workflows, and quality expectations  Support onboarding of new team members by providing clinical context and program knowledge  Ensure teams understand clinical requirements that impact operations, payments, or partner experience  Develop data visualizations with Excel or PowerBI  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  Skills & Competencies  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  Success Indicators  High accuracy and consistency in clinical reviews and documentation  Improved quality metrics and reduced clinical‑related escalations  Strong cross‑functional alignment between clinical and business teams  Clear, effective communication that supports partners and internal stakeholders  Scalable clinical processes that support operational growth and efficiency  Who is SmartLight Analytics  SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.