Clinical Operations Program Manager – UM Operations

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

📋 Description

• Oversee and prioritize operational projects, market support activities, Clinical Appeals or Utilization Management (UM) support requirements, audit deliverables, compliance initiatives, workflow enhancements, and system/process improvement requests.

• Facilitate Utilization Management and Clinical Appeals operational projects through project planning, workflow development, implementation coordination, stakeholder engagement, and post-implementation assistance.

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

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

• Monitor regulatory and contractual obligations, coordinate updates to workflows and documentation, assess risks, and escalate barriers as needed.

• Coordinate project specifications, reporting requirements, process modifications, and system impacts with internal stakeholders.

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

• Assist in new business activities, market launches, operational transitions, implementations, testing, training, and follow-up after going live.

• Conduct source system validation and data verification, participate in live regulatory audits, retrieve and verify audit documentation, and ensure workflows comply with policies and procedures.

• Analyze UM and appeals data along with regulatory reports; identify inconsistencies, investigate root causes, and support corrective actions and reporting preparation.

• Support audit feedback, report trends, gather stakeholder feedback, assess workflow performance, implement corrective actions, and formulate process improvement strategies.

• Provide status updates, 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 tasks, 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 documents.

⛳️ Requirements

• A Bachelor's degree in nursing, business management, or a related field is required, or equivalent years of relevant work experience may be considered in lieu of the required education.

• At least five years of experience in the healthcare sector is required.

• A minimum of two 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 preparedness, compliance activities, clinical systems, or healthcare payer operational projects is preferred.

• Proficiency 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 collaboration.

• Familiarity with Utilization Management and/or Clinical Appeals.

• Strong understanding of the healthcare payer industry, including Medicaid and Medicare.

• Ability to interpret 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 various functional areas.

• Clinical licensure is necessary.

• A Registered Nurse (RN) license is preferred.

• Six Sigma Certification is preferred.

• Capability to work independently as well as collaboratively within a team environment.

• Ability to document, track, and manage business requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle.

• Strong prioritization skills to ensure timely delivery of projects within budget while meeting stakeholder expectations.

🏝️ Benefits

• Bonus opportunities linked to both company and individual performance may be available.

• A comprehensive total rewards package.

• Support for total well-being for employees.

• Up to 15% occasional travel may be required based on departmental needs.