Sr Manager, Clinical UM Operations - Automation

Healthfirst, Inc.; New York (NY); Hybrid; USD 123,000 - 188,000; Full time

Benefits offered by this job

Health benefits

401k contributions

Job summary

Healthfirst, Inc. seeks a Senior Manager, Clinical Utilization Management (UM) to lead modernization and transformation of UM operations in a large health plan environment.

You will drive future-state workflows, partner with executives, and manage clinicians, ensuring compliant, high-quality, member-centered operations. You will oversee prior authorization, concurrent review, and service requests, while guiding a multidisciplinary team of RNs, social workers, and coordinators.

Qualifications

• Bachelor's degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience.
• New York State RN license (NYS RN).
• Strong understanding of UM regulatory requirements and managed care operations.
• Experience leading multidisciplinary clinical teams and coaching.
• Excellent analytical, organizational, and problem-solving abilities.
• Proven written and verbal communication skills with cross-functional influence.
• Track record of high performance in fast-paced, regulated environments.

Responsibilities

• Partner with UM Directors and VP to design and implement future-state UM workflows and operating practices.
• Collaborate with UM leadership, consultants, PM, technology, and vendors to support UM transformation priorities.
• Provide UM operational expertise to identify requirements, risks, dependencies, and impacts to frontline teams.
• Support readiness and adoption of new technologies, training, and stabilization.
• Apply AI, automation, and emerging tech to improve UM operations while aligning with clinical workflows and compliance.
• Oversee all utilization management functions including prior authorization, concurrent review, and service requests.
• Lead, coach, and develop UM managers overseeing interdisciplinary teams of clinicians and coordinators.
• Ensure compliance with CMS, NYSDOH, and other regulatory requirements.
• Establish and report KPIs, productivity, and quality metrics.
• Coordinate with Clinical Operations, Quality, Compliance, and Provider Relations for alignment.
• Utilize data analytics to identify trends and optimize resource allocation.
• Lead readiness for audits and corrective actions in UM.
• Foster accountability and continuous improvement across the team.
• Serve as SME and escalation point for complex cases needing clinical judgment.
• Support system implementations and technology enhancements for automation and reporting.
• Maintain timely service authorizations and reviews per turnaround times.

Skills

Nursing leadership

Healthcare operations

Regulatory knowledge

Analytical skills

Communication skills

Project management

Education

Bachelor's degree in Nursing / Healthcare Administration

NYS RN license

Tools

Milliman Care Guidelines (MCG)

Job description

The Senior Manager, Clinical Utilization Management (UM) Operations provides strategic and operational leadership for UM activities, with a key focus on advancing UM modernization and transformation. This role partners closely with the Vice President, internal UM leadership, external consultants, and project management resources to shape future-state workflows, support technology-enabled transformation, and drive operational readiness and adoption. The Senior Manager also oversees people leaders responsible for clinicians and coordinators performing 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 operational improvement.

Duties/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

MinimumQualifications:

• 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

Preferred Qualifications:

• Demonstrated experience delivering AI-enabled platforms, advanced analytics solutions or new software platforms solutions within healthcare operations
• Experience managing enterprise software implementations with vendors, systems integrators, and internal IT teams
• Demonstrated ability to translate clinical and operational requirements into business processes, workflows, and technology requirements.
• Strong analytical skills with experience using operational data, KPIs, and performance metrics to identify opportunities and drive improvement.
• Prior experience leading a team of people leaders
• Work experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements.
• Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS
• Experience working and/or managing in a virtual environment
• Understanding of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP)
• Experience working as a case manager for a long-term care programs such as PACE, MAP or MLTC
• Strong understanding of value-based care principles and their application to MLTC populations
• Experience accessing and maintaining patient health information (PHI) electronically in a shared network
• Strong computer skills, including, but not limited to word processing, spreadsheets, and databases

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $122,900 - $188,020

All Other Locations (within approved locations): $105,100 - $160,480

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to [e-mail] or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e‑mail address and phone number supplied. Thank you for considering a career with HF Management Services, LLC. Know Your Rights