AI-Driven Clinical UM Operations Leader

HealthFirst; United States; On-site; USD 123,000 - 188,000; Full time

Job summary

HealthFirst seeks a Senior Manager, Clinical Utilization Management Operations to provide strategic and operational leadership for UM activities, focusing on modernization and transformation. You will oversee leaders who manage clinicians and coordinators in medical necessity review, service authorization, care coordination, and related UM functions.

The role ensures compliant, high-quality, member-centered operations while driving standardization, efficiency, and sustainable improvement.

Qualifications

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience
• NYS RN
• Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
• Leadership experience in managing, coaching and developing multidisciplinary clinical teams
• Strong analytical, organizational, and problem-solving skills
• Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions
• Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment

Responsibilities

• Partner with UM Directors and the Vice President to advance the design and implementation of future-state UM workflows, processes, and operating practices that support modernization, standardization, and scalability
• Collaborate with UM leadership, external consultants, project management, technology, and vendor teams to support execution of UM transformation priorities and translate operational needs into practical solutions
• Contribute UM operational expertise to transformation initiatives, helping identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams
• Support operational readiness and adoption of new technologies, workflows, and capabilities by partnering with leaders and project teams on stakeholder engagement, training, implementation, and stabilization
• Apply experience with AI, automation, and other emerging technologies to help identify and advance opportunities that improve UM operations while ensuring solutions align with clinical workflows, compliance, audit requirements, and user needs
• Provide strategic oversight and operational management for all utilization management functions, including prior authorization, concurrent review, and service requests
• Lead, coach, and develop UM managers overseeing interdisciplinary teams of registered nurses, social workers, clinicians, and coordinators
• Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
• Establish, monitor, and report on key performance indicators (KPIs), productivity, and quality metrics to ensure compliance and optimal performance
• Partner with Clinical Operations, Quality, Compliance, and Provider Relations to ensure alignment and effective communication across departments
• Utilize data analytics and reporting tools to identify trends, drive process improvements, and optimize resource allocation
• Lead readiness efforts for audits, performance improvement plans, and corrective actions related to utilization management
• Foster a culture of accountability, professional development, and continuous improvement across all levels of the team
• Serve as a subject matter expert and escalation point for complex or high-impact cases requiring clinical and operational judgment
• Support system implementations and technology enhancements to improve automation, reporting, and member/provider experience
• Ensure the department maintains timely and accurate completion of service authorizations and reviews in alignment with turnaround time standards
• Additional duties as assigned

Skills

Leadership experience

Analytical skills

Communication skills

Regulatory knowledge

Multidisciplinary teams

Operational leadership

Education

Bachelor’s degree in Nursing, Healthcare Administration, or a related field

NYS RN

Job description

HealthFirst seeks a Senior Manager, Clinical Utilization Management Operations to provide strategic and operational leadership for UM activities, focusing on modernization and transformation. You will oversee leaders who manage clinicians and coordinators in medical necessity review, service authorization, care coordination, and related UM functions.

The role ensures compliant, high-quality, member-centered operations while driving standardization, efficiency, and sustainable improvement.