Sr Manager, Clinical UM Operations - Automation

HealthFirst•Remote - NY, NY

1d•$105,100 - $188,020

About The Position

The Senior Manager, Clinical Utilization Management (UM) Operations provides strategic and operational leadership for UM activities, with a focus on advancing UM modernization and transformation. The role partners with the Vice President, internal UM leadership, external consultants, and project management resources to shape future-state workflows, support technology-enabled transformation, and drive operational readiness and adoption. The Senior Manager also oversees people leaders responsible for clinicians and coordinators performing medical necessity review, service authorization, care coordination, and related UM functions. The role ensures compliant, high-quality, member-centered operations while driving standardization, efficiency, and sustainable operational improvement.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, or a related field from an accredited institution, or equivalent work experience.
New York State RN license.
Demonstrated understanding of UM regulatory requirements, clinical review processes, and managed care operations.
Leadership experience managing, coaching, and developing multidisciplinary clinical teams.
Strong analytical, organizational, and problem-solving skills.
Written and verbal communication skills, with the ability to influence and collaborate across functions.
Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.

Nice To Haves

Experience delivering AI-enabled platforms, advanced analytics solutions, or new software platform solutions within healthcare operations.
Experience managing enterprise software implementations with vendors, systems integrators, and internal IT teams.
Ability to translate clinical and operational requirements into business processes, workflows, and technology requirements.
Strong analytical skills and experience using operational data, KPIs, and performance metrics to identify opportunities and drive improvement.
Prior experience leading a team of people leaders.
Experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.
Ability to interpret and operationalize regulatory updates and guidance from the Department of Health and CMS.
Experience working and/or managing in a virtual environment.
Understanding of health plans such as Medicare, Medicaid, and/or Managed Long-Term Care Plans (MLTCP).
Experience working as a case manager for long-term care programs such as PACE, MAP, or MLTC.
Strong understanding of value-based care principles and their application to MLTC populations.
Experience accessing and maintaining patient health information (PHI) electronically in a shared network.
Strong computer skills, including word processing, spreadsheets, and databases.

Responsibilities

Partner with UM Directors and the Vice President to advance the design and implementation of future-state UM workflows, processes, and operating practices that support modernization, standardization, and scalability.
Collaborate with UM leadership, external consultants, project management, technology, and vendor teams to support execution of UM transformation priorities and translate operational needs into practical solutions.
Contribute UM operational expertise to transformation initiatives by identifying clinical and operational requirements, risks, dependencies, and impacts to frontline teams.
Support operational readiness and adoption of new technologies, workflows, and capabilities, including stakeholder engagement, training, implementation, and stabilization.
Apply experience with AI, automation, and emerging technologies to identify and advance opportunities that improve UM operations while aligning solutions with clinical workflows, compliance, audit requirements, and user needs.
Provide strategic oversight and operational management for utilization management functions, including prior authorization, concurrent review, and service requests.
Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators.
Ensure UM operations meet regulatory requirements established by CMS, the New York State Department of Health, and other oversight entities.
Establish, monitor, and report on key performance indicators, productivity, and quality metrics to support compliance and optimal performance.
Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments.
Use data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation.
Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management.
Foster a culture of accountability, professional development, and continuous improvement across the team.
Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment.
Support system implementations and technology enhancements to improve automation, reporting, and member and provider experience.
Ensure timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards.
Perform additional duties as assigned.