Executive Escalations and Clinical Review Manager

Executive Escalations & Clinical Review Manager

Fully Remote

About SCAN

SCAN Group is a not-for-profit organization dedicated to tackling the most pressing issues facing older adults in the United States. SCAN Group is the sole corporate member of SCAN Health Plan, one of the nation's leading not-for-profit Medicare Advantage plans, serving more than 270,000 members in California, Arizona, and Nevada. SCAN has been a mission-driven organization dedicated to keeping seniors healthy and independent for more than 40 years and is known throughout the healthcare industry and nationally as a leading expert in senior healthcare. SCAN employees are a group of talented, passionate professionals who are committed to supporting older adults on their aging journey, while also innovating healthcare for seniors everywhere. Employees are provided with in-depth training and access to state-of-the-art tools necessary to do their jobs, as well as development and growth opportunities. SCAN takes great pride in recognizing our team members as experts in their fields and rewarding them for their efforts. If you are interested in becoming part of an organization that is innovating senior healthcare visit www.thescangroup.org, www.scanhealthplan.com, or follow us on LinkedIn, Facebook, and Twitter.

The job

Responsible for leading the investigation, resolution, closure and summary reporting of member and provider complaints escalated through executive leadership, regulators, or legal channels. Serving as a clinical subject matter expert, this role ensures accurate identification and escalation of executive escalations, quality of care or clinical concerns through the review of member interactions. The manager fosters strong cross-functional relationships to support root cause resolution and continuous improvement.

You will

• 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.

Your qualifications

• 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 expereince or demonstrated equivalent writing skills.
• Cross-functional collaboration experience.
• Grievance and appeals handling expereince.
• 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.
• Bilingual ability is strongly recommended.
• 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.

What's in it for you?

• Base Pay Range: $92,400.00 to $166,320.00 USD
• Work Mode: Remote
• 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
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. #LI-JR1