Senior Manager, Clinical UM Operations – Automation

Healthfirst

. Provide strategic and operational leadership for clinical utilization management activities, focusing on UM modernization and transformation .

Posted 9/24/2026full-timeUnited StatesSenior💰 $122,900 - $188,020 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical utilization management, focusing on workflow design, regulatory compliance, and technology integration. Proven ability to lead multidisciplinary teams, drive performance improvement, and implement data-driven strategies in healthcare operations.

Highest-signal resume keywords

Clinical Utilization ManagementLeadership in Multidisciplinary TeamsRegulatory Compliance (CMS, NYS DOH)AI-Enabled Platforms and Advanced AnalyticsOperational Data Analysis and KPI Monitoring

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Review ProcessManaged Care OperationsWorkflow Design and ImplementationPerformance Metrics AnalysisMilliman Care Guidelines (MCG)Patient Health Information (PHI) ManagementEnterprise Software ImplementationData Analytics ToolsQuality Improvement PlansValue-Based Care Principles

Soft Skills

Analytical SkillsOrganizational SkillsProblem-Solving SkillsWritten and Verbal CommunicationCollaboration and Influence

Tools & Technologies

Healthcare Management SoftwareData Reporting ToolsAI and Automation TechnologiesSpreadsheets and DatabasesProject Management Tools

Certifications & Qualifications

Bachelor’s Degree in Nursing or Healthcare AdministrationNYS RN License

Industry Keywords

MedicareMedicaidManaged Long-Term Care Plan (MLTCP)Clinical Utilization ManagementHealthcare Operations

About the role

Key responsibilities & impact

Provide strategic and operational leadership for clinical utilization management activities, focusing on UM modernization and transformation
Partner with the Vice President, UM leadership, external consultants, and project management resources to shape future-state workflows and support technology-enabled transformation
Oversee people leaders responsible for medical necessity review, service authorization, care coordination, and related UM functions
Design and implement future-state UM workflows, processes, and operating practices
Collaborate with leadership, consultants, project management, technology, and vendor teams on UM transformation priorities
Identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams
Support stakeholder engagement, training, implementation, operational readiness, adoption, and stabilization of new technologies and workflows
Identify and advance AI, automation, and emerging technology opportunities aligned with clinical workflows, compliance, audit requirements, and user needs
Provide oversight for prior authorization, concurrent review, and service requests
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 resource allocation
Lead audit readiness, performance improvement plans, and corrective actions
Serve as a subject matter expert and escalation point for complex cases
Support system implementations and technology enhancements
Ensure timely and accurate completion of authorizations and reviews

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 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
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
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 coverage
Dental coverage
Vision coverage
Incentive and recognition programs
Life insurance
401k contributions
Competitive compensation and benefits package