Sr Manager Clinical UM Operations - Hybrid NY

Healthfirst; New York (NY); Hybrid; USD 119,900 - 183,430; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Life insurance

401k contributions

Job summary

Healthfirst is seeking a Senior Manager, Clinical Utilization Management (UM) Operations to lead all UM activities ensuring effective service delivery. You will oversee a team of managers and ensure compliance with state and federal regulations while driving operational excellence.

The ideal candidate will have a Bachelor's degree in Nursing or Healthcare Administration, NYS RN certification, and proven leadership experience in managing clinical teams, aiming for high performance and quality outcomes.

Qualifications

• Bachelor’s degree from an accredited institution or equivalent experience.
• NYS RN certification required.
• Understanding of UM regulatory requirements and clinical review process.

Responsibilities

• Provide oversight for all utilization management functions.
• Lead, coach, and develop UM managers overseeing clinical teams.
• Ensure compliance with regulatory requirements set by CMS and DOH.

Skills

Leadership in managing clinical teams

Analytical skills

Communication skills

Problem-solving skills

Education

Bachelor’s degree in Nursing or Healthcare Administration

NYS RN

Tools

Milliman Care Guidelines (MCG)

Data analytics and reporting tools

Job description

Overview

The Senior Manager, Clinical Utilization Management (UM) Operations is responsible for the strategic and operational leadership oversight of all utilization management activities, ensuring effective, compliant, and high‑quality service delivery. This role oversees a team of people leaders who manage clinicians and coordinators responsible for medical necessity review, service authorization, care coordination activities, and other related UM functions. The Senior Manager ensures compliance with all state and federal regulations, contractual obligations, and organizational policies while driving operational excellence, clinical quality, and member‑centered outcomes.

Responsibilities

• 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, NewYorkState 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.
• Perform additional duties as assigned.

Minimum 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.

Preferred Qualifications

• 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 program 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.

Equal Opportunity Employer

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.

Compensation and Benefits

Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $119,900 – $183,430. All Other Locations (within approved locations): $102,600 – $156,655.

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).