Clinical Operations Program Manager--UM Operations
New
J
JobgetherHealthcare
USFull-TimeMiddle
SalaryBase salary range of $113,000–$197,700 per year.
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Job Details
- Experience
- 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.
- Required Skills
- Project ManagementData AnalysisMicrosoft OfficeProcess improvement
Requirements
- Bachelor's degree in Nursing, Business Management, or a related field; or equivalent relevant experience.
- Clinical licensure required (Registered Nurse preferred).
- At least 5 years of experience in healthcare.
- At least 2 years of experience in project management, program management, operational implementation, or cross-functional business support.
- Strong knowledge of Utilization Management and/or Clinical Appeals.
- Understanding of healthcare payer industry, including Medicaid and Medicare.
- Knowledge of audit readiness, quality monitoring, regulatory compliance, and healthcare payer workflows.
- Proficiency with Microsoft Office tools (Project, Word, PowerPoint, Excel, Visio, Teams, Outlook).
- Experience with workflow design, process improvement, and data validation.
- Six Sigma certification preferred.
Responsibilities
- Manage and coordinate projects across UM and Clinical Appeals, ensuring operational initiatives, market implementations, and compliance requirements are delivered on time.
- Partner with market leadership and operational stakeholders on new market implementations, product changes, and operational readiness.
- Collaborate with Training and Auditing teams on audit tools, documentation, quality monitoring, and remediation planning.
- Track regulatory and contractual requirements, update workflows, and monitor risks affecting appeals or timeliness standards.
- Analyze UM and appeals data and regulatory reports for accuracy and compliance, investigating root causes for discrepancies.
- Participate in live regulatory audits and validate operational workflows against documented policies and procedures.
- Support leadership with regulatory reporting analysis, submission readiness, and program metrics.
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