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.