Senior Manager, Clinical UM Operations – Automation

Healthfirst

. Provide strategic and operational leadership for clinical utilization management activities .

Posted 11/2/2026full-timeRemote • New York • United StatesSenior💰 $105,100 - $160,480 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical utilization management, regulatory compliance, and operational leadership within healthcare settings. Proficient in leveraging data analytics and emerging technologies to enhance workflows and drive performance improvements.

Highest-signal resume keywords

Clinical Utilization ManagementRegulatory ComplianceData AnalyticsLeadership ExperienceAI-Enabled Platforms

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Review ProcessManaged Care OperationsPerformance MetricsEnterprise Software ImplementationsMilliman Care Guidelines (MCG)Value-Based Care PrinciplesPatient Health Information (PHI) ManagementOperational Data AnalysisWorkflow DevelopmentKPI Monitoring

Soft Skills

Analytical SkillsOrganizational SkillsProblem-Solving SkillsWritten CommunicationVerbal Communication

Tools & Technologies

Data Reporting ToolsAI TechnologiesHealthcare Software PlatformsSpreadsheetsDatabases

Certifications & Qualifications

Bachelor’s Degree in NursingNYS RN

Industry Keywords

CMS ComplianceNew York State DOHMedicareMedicaidManaged Long-Term Care Plan (MLTCP)Care CoordinationPrior AuthorizationConcurrent ReviewInterdisciplinary TeamsVirtual Environment Management

About the role

Key responsibilities & impact

Provide strategic and operational leadership for clinical utilization management activities
Advance future-state UM workflows, processes, and operating practices
Collaborate with UM leadership, consultants, project management, technology, and vendor teams on transformation priorities
Identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams
Support readiness and adoption of new technologies, workflows, and capabilities through engagement, training, implementation, and stabilization
Identify and advance AI, automation, and emerging technology opportunities for UM operations
Oversee prior authorization, concurrent review, service requests, care coordination, and related UM functions
Lead, coach, and develop UM managers overseeing interdisciplinary clinical teams
Ensure compliance with CMS, New York State DOH, and other regulatory requirements
Establish, monitor, and report KPIs, productivity, and quality metrics
Partner with Clinical Operations, Quality, Compliance, and Provider Relations
Use data analytics and reporting tools to identify trends, improve processes, and optimize resources
Lead audit readiness, performance improvement plans, and corrective actions
Serve as subject matter expert and escalation point for complex or high-impact cases
Support system implementations and technology enhancements
Ensure timely and accurate completion of authorizations and reviews according to turnaround standards

Requirements

What you’ll need

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 managing, coaching, and developing multidisciplinary clinical teams
Strong analytical, organizational, and problem-solving skills
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
Experience delivering AI-enabled platforms, advanced analytics solutions, or new software platforms within healthcare operations
Experience managing enterprise software implementations with vendors, systems integrators, and internal IT teams
Ability to translate clinical and operational requirements into business processes, workflows, and technology requirements
Experience using operational data, KPIs, and performance metrics to identify opportunities and drive improvement
Prior experience leading a team of people leaders
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 Medicare, Medicaid, and/or Managed Long-Term Care Plan (MLTCP)
Experience as a case manager for 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 word processing, spreadsheets, and databases

Benefits

Comp & perks

Medical, dental, and vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package