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Medica

To better your life with care in the moments that matter.

Utilization Review III

ManagerManagerFull TimeRemoteMid LevelTeam 1,001-5,000Since 1975H1B SponsorCompany SiteLinkedIn

Location

United States

Posted

12 days ago

Salary

$70.2K - $120.4K / year

Seniority

Mid Level

No structured requirement data.

Job Description

Utilization Review III

Medica

Role Description The Utilization Review III position is responsible for the review, investigation, and resolution of member and provider appeals and grievances requiring clinical expertise. This role ensures compliance with regulatory requirements, accreditation standards, and organizational policies while promoting quality outcomes, member satisfaction, and STARs performance. The specialist works collaboratively with medical directors, clinical staff, and operational teams to support timely and accurate determinations and oversee clinician-to-clinician (C2C) challenge activities. - Conduct clinical review of member and provider appeals, including pre-service, concurrent, and post-service cases. - Evaluate medical necessity, appropriateness of care, and benefit coverage using clinical guidelines and evidence-based criteria. - Investigate grievances by reviewing medical records, claims, and related documentation to determine root cause and resolution. - Prepare clear, concise, and compliant determination letters that meet regulatory and accreditation standards (e.g., CMS, NCQA). - Collaborate with Medical Directors for cases requiring physician review and support case presentations as needed. - Oversee and support Clinician-to-Clinician (C2C) challenges, including coordination, documentation, and ensuring timely completion in accordance with regulatory requirements. - Monitor and assess the impact of appeals and grievances on STARs measures, identifying trends, risks, and opportunities for performance improvement. - Partner with quality and operations teams to address trends that may negatively impact STARs ratings and member experience. - Ensure all appeals and C2C activities are processed within required turnaround times. - Identify trends, quality concerns, and potential process improvement opportunities through case analysis. - Maintain accurate and complete documentation in case management systems. - Serve as a clinical resource for non-clinical staff regarding appeals, grievance processes, and clinical escalation pathways. - Participate in audits, regulatory reporting, and quality improvement initiatives as required. Qualifications - Active, unrestricted clinical license (RN or LPN license required). - Minimum of 2–3 years of clinical experience (e.g., hospital, utilization management, case management). - Prior experience in Appeals & Grievances, Utilization Management, or Managed Care strongly preferred. - Experience with C2C processes, regulatory turnaround requirements, and STARs metrics preferred. Requirements - Strong knowledge of medical terminology, clinical guidelines, and healthcare delivery systems. - Understanding of regulatory requirements (CMS, Medicare/Medicaid, commercial guidelines, NCQA standards). - Familiarity with STARs measures and how clinical decisions impact quality performance outcomes. - Excellent critical thinking and clinical decision-making skills. - Strong written and verbal communication skills, including the ability to translate clinical information into member-friendly language. - Exceptional attention to detail and organizational skills. - Ability to manage multiple priorities and meet strict deadlines. - Proficiency in case management systems and Microsoft Office applications. Benefits - Competitive medical, dental, and vision plans. - PTO and Holidays. - Paid volunteer time off. - 401K contributions. - Caregiver services. - Generous total rewards package to support employees. Eligibility to work in the US Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. Equal Opportunity Employer We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.

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TikTok Shop Manager

Lago

We connect talented individuals from emerging markets with top-tier remote job opportunities.

Manager12 days ago
Full TimeRemoteTeam 1-10Since 2024H1B No Sponsor

Role Description We are looking for an experienced and highly organized TikTok Shop Manager to take ownership of a growing TikTok Shop operation. This role is both strategic and hands-on, requiring someone who can manage day-to-day execution while building the foundation for long-term growth. In the short term, this person will focus on cleaning up and organizing the existing TikTok Shop ecosystem. Over time, this role will evolve into a leadership position with direct reports, overseeing a team and driving overall performance. This is a high-impact role for someone who understands TikTok Shop deeply and can operate both as an individual contributor and a future team lead. Key Responsibilities - Oversee daily operations of the TikTok Shop account - Coordinate directly with TikTok representatives and partners - Manage product listings, updates, and optimization - Create and manage new product listings - Ensure accuracy, completeness, and performance optimization of listings - Organize catalog structure for scalability - Work with creators and affiliates to drive product promotion - Coordinate campaigns and ensure smooth execution - Support relationship management with creators - Clean up and organize existing workflows and systems - Build processes to support scaling the TikTok Shop operation - Identify inefficiencies and implement improvements - Transition into a management role overseeing a team - Delegate tasks and ensure accountability across team members - Help build and scale the TikTok Shop function internally Tools & Environment - TikTok Shop Seller Center - Communication tools (Slack, email, etc.) - Amazon MCF (Multi-Channel Fulfillment) Qualifications - Proven experience managing TikTok Shop accounts, +2 years of experience - Strong understanding of TikTok Shop operations, listings, and ecosystem - Experience coordinating with TikTok representatives - Ability to manage multiple workflows and stakeholders - Highly organized with strong attention to detail - Strong communication skills in English (C1) - Comfortable working in a fast-paced, evolving environment Nice-to-Haves - Experience with Amazon (especially Multi-Channel Fulfillment - MCF) - Experience working with creators or affiliate programs - Previous experience in a leadership or management role - Background in eCommerce operations Ideal Candidate Profile - Highly organized and process-driven - Able to balance strategy with execution - Strong sense of ownership and accountability - Comfortable building systems from the ground up - Effective communicator who can manage both internal and external stakeholders Remote Work - Work from anywhere—our team is global, and we value work-life balance. Growth Opportunities - As a key player, you’ll have the chance to shape your role and grow with us. Innovative Culture - Join a team that is passionate about leveraging data to solve challenges and drive success in a rapidly evolving market. As part of our recruitment process, all candidates are kindly asked to read, understand, and agree to Lago’s Confidentiality and Non-Circumvention Agreement. This ensures a respectful and professional experience for everyone involved.

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