Senior Manager, Clinical UM Operations – Automation

🔥 52 minutes ago

🗽 New York – Remote

🗽 New York – Remote

💵 $105.1k - $160.5k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

Apply Now

Find Similar Remote Jobs

Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

📋 Description

• Provide strategic and operational leadership for clinical utilization management activities • Advance future-state UM workflows, processes, and operating practices • Collaborate with UM leadership, consultants, project management, technology, and vendor teams on transformation priorities • Identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams • Support readiness and adoption of new technologies, workflows, and capabilities through engagement, training, implementation, and stabilization • Identify and advance AI, automation, and emerging technology opportunities for UM operations • Oversee prior authorization, concurrent review, service requests, care coordination, and related UM functions • Lead, coach, and develop UM managers overseeing interdisciplinary clinical teams • Ensure compliance with CMS, New York State DOH, and other regulatory requirements • Establish, monitor, and report KPIs, productivity, and quality metrics • Partner with Clinical Operations, Quality, Compliance, and Provider Relations • Use data analytics and reporting tools to identify trends, improve processes, and optimize resources • Lead audit readiness, performance improvement plans, and corrective actions • Serve as subject matter expert and escalation point for complex or high-impact cases • Support system implementations and technology enhancements • Ensure timely and accurate completion of authorizations and reviews according to turnaround standards

🎯 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 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 • Experience delivering AI-enabled platforms, advanced analytics solutions, or new software platforms 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 • 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 DOH and CMS • Experience working and/or managing in a virtual environment • Understanding of Medicare, Medicaid, and/or Managed Long-Term Care Plan (MLTCP) • Experience 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

🏖️ Benefits

• Medical, dental, and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Competitive compensation and benefits package

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume