Clinical Operations Program Manager--UM Operations

Team: Project Management

Location: US

Commitment: Full-time

Workplace Type: remote

Accountabilities:

You will manage and coordinate projects across UM and Clinical Appeals, ensuring operational initiatives, market implementations, compliance requirements, and process improvements are delivered accurately and on time.

• Manage and prioritize operational projects, market support activities, UM and Clinical Appeals needs, audit deliverables, compliance initiatives, workflow improvements, and system or process enhancement requests.
• Plan and coordinate UM and Clinical Appeals initiatives, including workflow development, implementation, stakeholder engagement, testing, and post-implementation support.
• Partner with market leadership and operational stakeholders on new market implementations, product changes, operational readiness, issue resolution, and market-specific requirements.
• Collaborate with Training and Auditing teams on audit tools, documentation, quality monitoring, trend identification, remediation planning, and audit readiness.
• Track regulatory and contractual requirements and coordinate updates to workflows and documentation while monitoring risks and escalating barriers that could affect appeals or timeliness standards.
• Define and prioritize project requirements, reporting needs, process changes, and system impacts with cross-functional stakeholders.
• Maintain project plans, action logs, issue trackers, status reports, decision logs, and other project management documentation.
• Support new business activities, market launches, operational transitions, and implementations by coordinating requirements, workflows, communications, testing, training, and post-go-live activities.
• Perform source-system validation and data verification for audit responses and regulatory activities, including retrieving and validating supporting documentation.
• Participate in live regulatory audits and validate operational workflows against documented policies and procedures.
• Analyze UM and appeals data and regulatory reports for completeness, accuracy, and compliance; investigate discrepancies and root causes and coordinate corrective actions.
• Support leadership with regulatory reporting analysis, submission readiness, program metrics, and business decision materials.
• Develop and monitor action plans based on audit findings, reporting trends, stakeholder feedback, and workflow performance.
• Provide regular program and project updates to senior management, executive sponsors, stakeholders, and impacted business areas.
• Represent UM Operations and Clinical Appeals in governance, prioritization, intake, and cross-functional workgroups.
• Coordinate vendor-related operational activities, including onboarding, issue resolution, workflow integration, and performance monitoring.
• Manage SharePoint sites, document repositories, meeting materials, project artifacts, and operational reference documentation.
• Contribute to continuous improvement initiatives and other job-related projects as needed.

Requirements:

The ideal candidate combines healthcare industry knowledge with strong program management, analytical, communication, and problem-solving capabilities. You should be comfortable navigating regulated environments, coordinating complex cross-functional initiatives, and managing detailed documentation and data validation.

• Bachelor's degree in Nursing, Business Management, or a related field required; equivalent relevant experience may be accepted in lieu of education.
• At least 5 years of healthcare experience.
• At least 2 years of experience in project management, program management, operational implementation, or cross-functional business support.
• Experience with Utilization Management or Clinical Appeals, market implementations, audit readiness, compliance, clinical systems, or healthcare payer operations preferred.
• Clinical licensure required; Registered Nurse (RN) license preferred.
• Six Sigma certification preferred.
• Strong knowledge of Utilization Management and/or Clinical Appeals.
• Strong understanding of the healthcare payer industry, including Medicaid and Medicare.
• Knowledge of audit readiness, quality monitoring, regulatory compliance, market operations, and healthcare payer workflows.
• Ability to interpret and analyze operational data, identify trends, validate reporting, and translate insights into action.
• Demonstrated ability in project management, workflow design, operational implementation, process improvement, and cross-functional coordination.
• Strong attention to detail and exceptional accuracy when reviewing documentation and validating data.
• Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook.
• Excellent written and verbal communication, critical thinking, active listening, interpersonal, and relationship-building skills.
• Strong decision-making and problem-solving abilities, with the judgment to shape approaches and build stakeholder consensus.
• Ability to prioritize competing assignments and deliver projects on time, within budget, and in line with stakeholder expectations.
• Ability to document and manage requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle.
• Ability to understand and implement regulatory and contractual requirements.
• Ability to work independently and collaboratively across multiple functional areas and organizational levels.
• Adaptable and flexible when working in changing regulatory and operational environments.
• Strong ownership, customer-service orientation, and ability to develop, prioritize, and accomplish goals.
• Willingness to review and apply evidence-based trends to operational improvement initiatives.

Benefits:

• Base salary range of $113,000–$197,700 per year.
• Eligibility for a bonus tied to company and individual performance.
• Remote, full-time position.
• Comprehensive total rewards package supporting employee well-being.
• Occasional travel of up to 15% based on departmental needs.
• Opportunity to work across Utilization Management, Clinical Appeals, healthcare operations, compliance, and process improvement.
• Exposure to senior management, executive sponsors, and cross-functional business teams.