Clinical Operations Program Manager - Clinical Appeals

caresource; Deutschland; Remote; EUR 70.000 - 90.000; Vollzeit

Zusammenfassung

caresource is seeking a Clinical Operations Program Manager to coordinate operational projects supporting Utilization Management and Clinical Appeals, ensuring market readiness and compliance across workflows.

The role focuses on audit readiness, data integrity, and cross-functional collaboration with market leadership, training, and auditing teams to improve processes and adherence to regulatory requirements.

Qualifikationen

• Bachelor's degree in nursing, business management or related field required.
• Five years of healthcare experience required.
• Two years of project/program management or related experience required.

Aufgaben

• Manage and prioritize operational projects and audit-related deliverables.
• Plan, coordinate, and support market implementations and readiness.
• Collaborate with stakeholders to ensure compliance and process improvements.
• Maintain project plans, logs and status updates for leadership review.

Kenntnisse

Project management

Healthcare operations

Regulatory compliance

Stakeholder engagement

Data analysis

Ausbildung

Bachelor's degree in nursing or related field

Equivalent work experience accepted

Tools

Microsoft Office

MS Project

Visio

Jobbeschreibung

Job Summary

The Clinical Operations Program Manager - UM Operations & Clinical Appeals is responsible for managing and coordinating operational projects or initiatives that support Utilization management (UM) and/or Clinical Appeals, market readiness activities, workflow improvements, activities that promote regulatory compliance, audit readiness, reporting accuracy, cross functional deliverables and continuous process improvement across Clinical Appeals and UM operations.

Essential Functions

• Manage and prioritize operational projects, market support activities, Clinical Appeals or UM support needs, audit-related deliverables, compliance initiatives, work flow improvements, and system/process enhancement requests to ensure timely completion and alignment with business needs.
• Support successful delivery of Utilization Management and Clinical Appeals operational initiatives through project planning, work flow development, implementation coordination, stakeholder engagement, and post-implementation support.
• Partner with market leadership, UM Operations, and Clinical Appeals stakeholders to support new market implementations, product changes, operational readiness, issue resolution, and ongoing market-specific needs.
• Collaborate with Training and Auditing teams to support UM and Clinical Appeals audit tools, audit readiness, process documentation, quality monitoring, trend identification, and remediation planning.
• Support compliance-related activities by tracking regulatory and contractual requirements, coordinating updates to UM and Clinical Appeals work flows and documentation, monitoring risks, and escalating barriers that may impact operational appeals, or timeliness standards.
• Coordinate with internal stakeholders to ensure project requirements, reporting needs, process changes, and system impacts are clearly defined and appropriately prioritized.
• Maintain project plans, action logs, issue trackers, status updates, and other project management tools to support accountability, transparency, and timely decision-making.
• Support new business activities, market launches, operational transitions, and other implementation efforts by coordinating requirements, work flows, communications, testing support, training needs, and post-go-live follow-up.
• Perform source system validation and data verification to support audit responses, Participate in live regulatory audits and audit activities, Coordinate retrieval and validation of supporting documentation requested during audits, Validate operational work flows against documented policies and procedures.
• Analyze operational and regulatory UM and appeals data; review regulatory reports for completeness, accuracy, and compliance; validate report data against source systems, operational databases, and supporting documentation; identify reporting discrepancies, investigate root causes, and collaborate with business partners to implement corrective actions; support leadership with regulatory reporting analysis and submission readiness.
• Support action plans and work required for audit feedback, reporting trends, stakeholder feedback, and work flow performance to identify improvement opportunities and support corrective action or process improvement plans.
• Provide regular status reporting, program and project metrics, business decision documents, and ongoing communication to senior management, stakeholders, executive sponsors, and impacted business areas.
• Represent UM Operations and Clinical Appeals in intake, governance, prioritization, and cross-functional workgroups related to operational projects, market support, audit readiness, compliance needs, and process enhancements.
• Support oversight and coordination of vendor-related operational activities, including vendor onboarding, issue resolution, work flow integration, performance monitoring, and alignment with UM Operations and Clinical Appeals business needs.
• Manage and maintain program/project documentation, including SharePoint sites or document repositories, meeting materials, decision logs, project artifacts, and operational reference materials.
• Perform any other job related duties as requested.

Education and Experience

• Bachelor's degree in nursing, business management or related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of healthcare experience required
• Two (2) years of project management, program management, operational implementation, or cross-functional business support experience required
• Experience supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance activities, clinical systems, or healthcare payer operational projects preferred

Competencies, Knowledge and Skills

Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, Outlook, etc.

High attention to detail with exceptional accuracy in documentation and d