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.
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