Healthfirst

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.

Duties/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, 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

 

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 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.