Purpose:If you're highly organized, proactive, and enjoy working with healthcare professionals, this role could be the perfect next step. The UPMC Health Plan is seeking a Utilization Management Physician Operations Manager to join a collaborative team where you'll work alongside physicians and clinical leaders to keep care moving forward efficiently and effectively.
The Utilization Management (UM) Physician Operations Manager is responsible for driving the operational effectiveness, coordination, and execution of Medical Director activities within the health plan. This role partners closely with Medical Directors, clinical leadership, and cross-functional teams to ensure efficient workflow execution, timely case progression, and seamless operational support. Serving as a critical liaison between clinical decision-makers and operational teams, this position enables Medical Directors to operate at the top of their license while maintaining compliance, efficiency, and high service standards. The role requires strong operational leadership, data-driven decision-making, and the ability to proactively identify and resolve workflow challenges.
This role is Hybrid and will require an onsite presence in Downtown Pittsburgh 3 days per week.
Responsibilities: - Scheduling, Coverage & Capacity Management:
- Own end-to-end Medical Director scheduling, including PTO, coverage, and workload balancing.
- Maintain centralized, real-time calendars (reviews, appeals, hearings, committees).
- Proactively identify and resolve coverage gaps using workload and volume data.
- Ensure equitable distribution of work during PTO, holidays, and unplanned absences.
- Serve as primary point of contact for scheduling, availability, and coverage coordination.
- Support short- and long-term capacity planning aligned to volumes and regulatory timelines.
- Provide reporting and insights on scheduling trends to inform staffing decisions.
- Medical Director Operational Support:
- Provide day-to-day operational support for Medical Directors across all core activities.
- Coordinate scheduling and prioritization of reviews, appeals, peer-to-peer calls, and hearings.
- Act as primary operational liaison for workflow, process, and scheduling inquiries.
- Lead onboarding and coordination of training for Medical Directors, including:
- System access and tools
- Regulatory and compliance training
- Role-specific workflows and expectations
- Monitor completion of required onboarding and training milestones
- Workflow & Process Optimization:
- Coordinate end-to-end workflows supporting Medical Director decision-making (intake, prioritization, tracking, and cross-functional handoffs).
- Partner with UM, Quality, Appeals, Legal, Pharmacy, Operations and other functional areas within the IDFS to ensure alignment.
- Proactively identify and partner to resolve operational inefficiencies, bottlenecks, and recurring issues.
- Drive continuous process improvement initiatives with measurable outcomes
- Meeting & Governance Coordination:
- Plan, schedule and support Medical Director meetings, committees, and case review sessions.
- Develop agendas, prepare materials, and manage logistics.
- Track decisions, risks, and action items to ensure accountability and follow-through.
- Support governance structures and documentation standards.
- Data, Reporting & Performance Insights.
- Monitor key operational metrics (volume, turnaround time, productivity, SLA performance) and lead weekly/monthly reporting to leadership.
- Develop dashboards and reports to support leadership visibility and decision-making.
- Analyze trends to inform staffing models, workload balancing, and process improvements.
- Provide actionable insights to drive operational efficiency and performance.
- Regulatory & Operational Readiness:
- Support audit readiness (NCQA, CMS, internal audits) and accreditation activities.
- Ensure workflows and documentation align with regulatory and compliance standards.
- Partner with compliance and quality teams to maintain operational integrity.
- Proactively address risks related to timeliness, documentation, and process adherence
Qualifications: - Bachelor's degree in Healthcare Administration, Business, Public Health, or related field (or equivalent experience).
- Experience in healthcare operations, managed care, utilization management, or medical management.
- Strong organizational, problem-solving, and execution skills in a high-volume, deadline-driven environment.
- Proven ability to work effectively with physicians and cross-functional teams.
- Strong analytical skills with experience building and leveraging dashboards and performance metrics .
- Experience supporting Medical Directors or physician leadership.
- Familiarity with UM, appeals/grievances, and health plan operations preferred.
Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.
