Sr Manager, Clinical UM Operations - Automation

HealthFirst•Hybrid - NY, NY

17d•$105,100 - $188,020•Hybrid

About The Position

The Senior Manager, Clinical Utilization Management (UM) Operations provides strategic and operational leadership for UM activities, with a key focus on advancing UM modernization and transformation. This role partners closely 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
NYS RN
Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
Leadership experience in managing, coaching and developing multidisciplinary clinical teams
Strong analytical, organizational, and problem-solving skills
Work experience demonstrating 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

Demonstrated experience delivering AI-enabled platforms, advanced analytics solutions or new software platforms solutions within healthcare operations
Experience managing enterprise software implementations with vendors, systems integrators, and internal IT teams
Demonstrated ability to translate clinical and operational requirements into business processes, workflows, and technology requirements.
Strong analytical skills with experience using operational data, KPIs, and performance metrics to identify opportunities and drive improvement.
Prior experience leading a team of people leaders
Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.
Ability to interpret and operationalize regulatory updates and guidance from DOH 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 Plan (MLTCP)
Experience working as a case manager for a 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, but not limited to 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, helping identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams.
Support operational readiness and adoption of new technologies, workflows, and capabilities by partnering with leaders and project teams on stakeholder engagement, training, implementation, and stabilization.
Apply experience with AI, automation, and other emerging technologies to help identify and advance opportunities that improve UM operations while ensuring solutions align with clinical workflows, compliance, audit requirements, and user needs.
Provide strategic oversight and operational management for all 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 set forth by CMS, New York State Department of Health (DOH), and other oversight entities
Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance
Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments
Utilize 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 all levels of 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/provider experience
Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards
Additional duties as assigned