Clinical Operations Program Manager – Clinical Appeals

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee and prioritize various operational projects, market support activities, Clinical Appeals or Utilization Management support requirements, audit-related tasks, compliance initiatives, workflow enhancements, and system/process improvement requests.

• Facilitate the execution of Utilization Management and Clinical Appeals operational initiatives by engaging in project planning, workflow development, implementation coordination, stakeholder communication, and post-implementation assistance.

• Collaborate with market leadership, UM Operations, and Clinical Appeals stakeholders regarding new market implementations, product modifications, operational readiness, issue resolution, and specific market needs.

• Work alongside Training and Auditing teams on audit tools, audit preparedness, process documentation, quality monitoring, trend analysis, and remediation strategies.

• Monitor regulatory and contractual obligations, coordinate updates to workflows and documentation, assess risks, and escalate any obstacles.

• Coordinate project requirements, reporting needs, process alterations, and system implications with internal stakeholders.

• Maintain project plans, action logs, issue trackers, status updates, and project management tools effectively.

• Assist in business activities, market launches, operational transitions, and implementation efforts through requirements coordination, workflow development, communication, testing, training, and post-go-live follow-up.

• Conduct source system validation and data verification for audit responses.

• Engage in regulatory audits; retrieve and validate supporting documentation; ensure workflows are in alignment with policies and procedures.

• Analyze operational and regulatory UM and appeals data; review and validate regulatory reports; identify discrepancies and their root causes; implement corrective measures; ensure readiness for reporting submissions.

• Support action plans and process improvement initiatives based on audit feedback, reporting trends, stakeholder input, and workflow performance.

• Provide status reports, program and project metrics, business decision documents, and communications to senior management, stakeholders, executive sponsors, and affected 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 tracking.

• Manage program and project documentation, including SharePoint sites, repositories, meeting materials, decision logs, project artifacts, and operational reference materials.

• Carry out other job-related tasks as assigned.

⛳️ Requirements

• A Bachelor's degree in nursing, business management, or a related field is required.

• Equivalent years of relevant work experience may be considered in lieu of the required education.

• A minimum of five (5) years of healthcare experience is required.

• At least two (2) years of experience in project management, program management, operational implementation, or cross-functional business support is required.

• Experience in supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance initiatives, clinical systems, or healthcare payer operational projects is preferred.

• Proficient in Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook.

• Proven skills in project management, workflow design, operational implementation, process enhancement, and cross-functional coordination.

• Strong knowledge of Utilization Management and/or Clinical Appeals processes.

• In-depth understanding of the healthcare payer industry, including Medicaid and Medicare.

• Ability to comprehend and implement regulatory and contractual requirements.

• Familiarity with audit readiness, quality monitoring, regulatory compliance, market operations, Utilization Management or Clinical Appeals, and healthcare payer operational workflows.

• Clinical licensure is required.

• Registered Nurse (RN) license is preferred.

• Six Sigma Certification is preferred.

• Capability to analyze processes across multiple functional areas.

• Proficiency in documenting, tracking, and managing business requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle.

• Ability to work both independently and collaboratively within a team environment.

🏝️ Benefits

• Potential bonus linked to company and individual performance.

• Comprehensive total rewards package.

• Employee total well-being support.

• Occasional travel opportunities up to 15% based on departmental needs.