SCAN · 2 days ago
Executive Escalations and Clinical Review Manager
United States
Full-time
Remote
Mid, Senior Level
$92K/yr - $166K/yr
2+ years expSCAN Group is a not-for-profit organization dedicated to tackling pressing issues facing older adults in the United States. The Executive Escalations and Clinical Review Manager is responsible for leading the investigation and resolution of member and provider complaints, ensuring quality of care through clinical reviews, and fostering cross-functional relationships to support continuous improvement.
Elder CareHealth CareHome Health CareMedical
Responsibilities
Lead the End-to-End Resolution of Executive and Regulatory Escalations Serve as the primary contact and accountable leader for the investigation, resolution, and response to high-visibility member complaints received through executive leadership. Ensure timely, accurate, and compliant resolution in alignment with internal policies and regulatory standards
Conduct Clinical Review of Member Interactions to Identify Quality of Care Concerns Review recorded member calls and other communications to assess missed or unaddressed clinical issues, quality of care concerns, or patient safety risks. Use clinical judgment to determine appropriate follow-up, and ensure timely escalation to Clinical Operations, Utilization Management, or Grievance and Appeals team for further action or intervention
Collaborate Cross-Functionally to Drive Root Cause Resolution Partner with internal teams to conduct thorough root cause analyses and implement effective, sustainable resolutions. Lead or contribute to the development of corrective action plans, process improvement, and resource development when systemic issues are identified
Prepare and Review High-Stakes Communications Prepare clear, professional, and empathetic written responses on behalf of executive leadership for internal and external stakeholders. Ensure accuracy, alignment with clinical and operational findings, and appropriate tone for sensitive or escalated issues
Monitor Trends and Support Quality Improvement Track and analyze escalation trends, with a focus on identifying patterns related to care quality, access, and service breakdowns. Provide feedback and insights to leadership to inform process improvements, staff coaching, and clinical quality initiatives aimed at reducing future escalations and improving member experience
Fosters Collaborative, Culturally-Aware Partnerships Builds effective professional relationships with providers and other internal and external partners utilizing verbal and written communication skills, developing trust, meeting timelines, respecting cultural differences, using active listening skills, and maintaining confidentiality
Serves as Subject Matter Expert and Department Liaison Serves as a subject matter expert and represents the department in internal and regulatory audits, at assigned committees to support two-way communication between department and committee and committee to department head and/or staff as appropriate
Professional Licensure and Technical Knowledge Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, participating in professional societies
We seek Rebels who are curious about Al and its power to transform how we operate and serve our members
All other duties as assigned
Qualification
Required
Bachelor's Degree required
Registered Nurse ( RN)
2+ years Medicare/Medi-Cal experience in managed care environment
Escalations and/or complaints handling experience
Analytical and root cause investigation experience
Executive level communication experience or demonstrated equivalent writing skills
Cross-functional collaboration experience
Grievance and appeals handling experience
Knowledge of CMS and DHCS grievance and appeals regulations
Quality auditing experience
Case management experience in a medical group, IPA and/or HMO setting preferred
Strategic Problem Solving- Resolves complex cases with sound judgment
Executive Communication- Writes and speaks clearly, professionally, and persuasively
Cross-Functional Collaboration- Partners with multiple teams to drive resolution
Accountability- Owns case outcomes end-to-end
Emotional Intelligence- Maintains empathy and calm under pressure
Strong written and oral communication skills, as well as strong interpersonal, critical thinking, and analytical skills
Demonstrated ability to work with all levels of staff, within and external to the organization to achieve goals
Ability to prioritize multiple and competing tasks
Ability to work independently or as a team while working in a fast-paced and dynamic environment
Basic knowledge of related NCQA standards, CMS and DHCS regulations
Medical and clinical terminology conversant
Preferred
Case management experience in a medical group, IPA and/or HMO setting preferred
Bilingual ability is strongly recommended
Benefits
An annual employee bonus program
Robust Wellness Program
Generous paid-time-off (PTO)- 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days
Excellent 401(k) Retirement Saving Plan with employer match
Robust employee recognition program
Tuition reimbursement
Company
SCAN
About SCAN Keeping Seniors Healthy and Independent–that’s been our mission for more than 40 years.
1001-5000 employees
H1B Sponsorship
SCAN has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (5)
2024 (3)
2023 (6)
2022 (6)
2021 (5)
2020 (6)
Funding
Current Stage
Late StageLeadership Team
Lyn Amor Macaraeg
CVP Chief of Staff & Strategic Advisor to the CEO
Sachin H. Jain, MD, MBA
President and CEO, Board Director
Recent News
2025-12-26
Company data provided by crunchbase