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:

• Lead the design and implementation of future-state UM operating models, workflows, and processes to support modernization, standardization, and scalability.
• Partner with the Vice President, UM leadership, external consultants, project management, technology, and vendor teams to drive execution of UM transformation priorities.
• Represent UM operations in transformation governance, ensuring clinical and operational requirements, risks, dependencies, and impacts are identified and addressed.
• Drive operational readiness and change adoption for new technologies, workflows, and capabilities, including stakeholder engagement, training, and transition to business-as-usual operations.
• Ensure AI solutions align with clinical operations, compliance standards, audit requirements, and user adoption objectives.
• 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:

• 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.