Clinical Operations Program Manager – UM Operations

🔥 13 hours ago

🇺🇸 United States – Remote

💵 $113k - $197.7k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥 Clinical Operations

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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CareSource

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 30+ years

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

CareSource is a health services company focused on providing affordable health insurance and healthcare solutions. It offers a wide range of plans including Medicaid, Marketplace, and Medicare Advantage, targeting low-income adults, families, children, pregnant women, elderly adults, and people with disabilities. Additionally, CareSource provides members with resources for COVID-19 support, dental, vision, and hearing benefits, as well as pharmacy services. The company emphasizes easy access to healthcare management through online platforms and a mobile app.

📋 Description

• Manage and prioritize operational projects, market support activities, Clinical Appeals or UM support needs, audit deliverables, compliance initiatives, workflow improvements, and system/process enhancement requests • Support Utilization Management and Clinical Appeals operational initiatives through project planning, workflow development, implementation coordination, stakeholder engagement, and post-implementation support • Partner with market leadership, UM Operations, and Clinical Appeals stakeholders on new market implementations, product changes, operational readiness, issue resolution, and market-specific needs • Collaborate with Training and Auditing teams on audit tools, audit readiness, process documentation, quality monitoring, trend identification, and remediation planning • Track regulatory and contractual requirements, coordinate workflow and documentation updates, monitor risks, and escalate barriers • Coordinate project requirements, reporting needs, process changes, and system impacts with internal stakeholders • Maintain project plans, action logs, issue trackers, status updates, and project management tools • Support new business activities, market launches, operational transitions, implementations, testing, training, and post-go-live follow-up • Perform source system validation and data verification, participate in live regulatory audits, retrieve and validate audit documentation, and validate workflows against policies and procedures • Analyze UM and appeals data and regulatory reports; identify discrepancies, investigate root causes, and support corrective actions and reporting submission readiness • Support audit feedback, reporting trends, stakeholder feedback, workflow performance, corrective actions, and process improvement plans • Provide status reporting, program and project metrics, business decision documents, and communications to senior management, stakeholders, executive sponsors, and impacted business areas • Represent UM Operations and Clinical Appeals in intake, governance, prioritization, and cross-functional workgroups • Coordinate vendor-related operational activities, including onboarding, issue resolution, workflow integration, and performance monitoring • Manage program/project documentation, SharePoint sites or document repositories, meeting materials, decision logs, project artifacts, and operational reference materials

🎯 Requirements

• Bachelor's degree in nursing, business management or related field required, or equivalent years of relevant work experience in lieu of required education • Five years of healthcare experience required • Two years of project management, program management, operational implementation, or cross-functional business support experience required • Experience supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance activities, clinical systems, or healthcare payer operational projects preferred • Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook • Demonstrated project management, workflow design, operational implementation, process improvement, and cross-functional coordination skills • Knowledge of Utilization Management and/or Clinical Appeals • Strong knowledge of the healthcare payer industry, Medicaid, and Medicare • Ability to understand and implement regulatory and contractual requirements • Knowledge of audit readiness, quality monitoring, regulatory compliance, market operations, Utilization Management or Clinical Appeals, and healthcare payer operational workflows • Ability to analyze processes across multiple functional areas • Clinical licensure required • Registered Nurse (RN) license preferred • Six Sigma Certification preferred • Ability to work independently and within a team environment • Ability to document, track, and manage business requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle • Ability to prioritize work and assignments to deliver projects on time, on budget, and meeting stakeholder expectations

🏖️ Benefits

• Bonus tied to company and individual performance may be available • Comprehensive total rewards package • Employee total well-being support • Up to 15% occasional travel based on department needs