Clinical Operations Program Manager - Clinical Appeals

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Clinical Operations Program Manager - Clinical Appeals based in United States. This role leads operational programs and initiatives supporting Utilization Management and Clinical Appeals within a complex healthcare environment. You will coordinate cross-functional projects spanning market readiness, workflow improvements, regulatory compliance, audit preparation, reporting accuracy, and process optimization. The position requires a strong combination of healthcare operations knowledge and project management expertise to translate business needs into effective operational solutions. You will work closely with clinical, operational, training, auditing, technology, and market stakeholders to deliver initiatives from planning through implementation and post-launch support. Your work will help strengthen compliance, improve reporting quality, resolve operational issues, and ensure consistent execution across markets. This is an opportunity to influence healthcare operations while working on high-impact initiatives in a dynamic and highly regulated environment.

Accountabilities You will manage and prioritize operational programs and projects, ensuring that initiatives supporting Clinical Appeals and Utilization Management are delivered effectively, accurately, and in alignment with regulatory, contractual, and business requirements.

• Manage operational projects, market support activities, Clinical Appeals and Utilization Management initiatives, audit deliverables, compliance efforts, workflow improvements, and system or process enhancement requests.
• Lead project planning, workflow development, implementation coordination, stakeholder engagement, testing, and post-implementation support.
• Partner with market leadership and clinical operations stakeholders on new market implementations, product changes, operational readiness, issue resolution, and market-specific requirements.
• Collaborate with Training and Auditing teams on audit tools, readiness activities, process documentation, quality monitoring, trend analysis, and remediation planning.
• Track regulatory and contractual requirements and coordinate updates to workflows, policies, and documentation to maintain compliance and meet required timeliness standards.
• Maintain project plans, action logs, issue trackers, decision logs, status reports, and other project management documentation.
• Coordinate requirements, reporting needs, process changes, and system impacts across internal stakeholders, ensuring priorities and dependencies are clearly defined.
• Support new business activities, market launches, operational transitions, and implementation programs through requirements gathering, communications, testing, training coordination, and post-go-live follow-up.
• Perform source-system validation and data verification for audit responses and regulatory activities, including retrieval and validation of supporting documentation.
• Participate in live regulatory audits and validate operational workflows against documented policies and procedures.
• Analyze Utilization Management and appeals data and regulatory reports for completeness, accuracy, and compliance; investigate discrepancies and collaborate on corrective actions.
• Support action plans arising from audit findings, reporting trends, stakeholder feedback, and workflow performance to identify and implement process improvements.
• Prepare program metrics, status reports, business decision documents, and executive-level communications for senior leaders and stakeholders.
• Represent Clinical Appeals and Utilization Management in governance, prioritization, intake, and cross-functional working groups.
• Coordinate vendor-related operational activities, including onboarding, issue resolution, workflow integration, performance monitoring, and ongoing alignment with business requirements.
• Maintain SharePoint sites, document repositories, meeting materials, decision logs, project artifacts, and operational reference documentation.

Requirements The ideal candidate combines healthcare industry experience with strong program management, analytical, communication, and process improvement capabilities. You should be comfortable working independently and collaboratively across multiple functional areas while navigating changing regulatory and operational requirements.

• Bachelor's degree in nursing, business management, or a related field; equivalent relevant experience may be accepted in lieu of the required education.
• At least 5 years of healthcare experience.
• At least 2 years of experience in project management, program management, operational implementation, or cross-functional business support.
• Experience supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance activities, clinical systems, or healthcare payer projects is preferred.
• Clinical licensure is required; an active Registered Nurse (RN) license is preferred.
• Strong knowledge of the healthcare payer industry, including Medicaid and Medicare.
• Knowledge of Utilization Management and/or Clinical Appeals processes and operational workflows.
• Understanding of regulatory and contractual requirements and their application to healthcare operations.
• Knowledge of audit readiness, quality monitoring, regulatory compliance, and market operations.
• Demonstrated ability to manage workflows, business requirements, risks, issues, decisions, action items, and deliverables throughout the project lifecycle.
• Experience with project management and productivity tools, including Microsoft Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook.
• Strong analytical skills with the ability to interpret operational data, identify trends, investigate discrepancies, and develop actionable insights.
• Exceptional attention to detail and accuracy in documentation, reporting, and data validation.
• Excellent written and verbal communication, critical thinking, listening, decision-making, and problem-solving skills.
• Strong relationship-building and stakeholder management capabilities, with the ability to interact effectively at all organizational levels.
• Ability to build consensus, influence stakeholders, prioritize competing demands, and drive projects toward successful outcomes.
• Adaptability and flexibility in a rapidly changing regulatory and operational environment.
• Ability to work independently while contributing effectively within a collaborative team.
• Ability to identify evidence-based trends and translate them into practical operational improvements.
• Six Sigma certification is preferred.
• Ability to develop, prioritize, and execute goals while maintaining stakeholder expectations and delivery timelines.

Benefits

• Salary range of $113,000 to $197,700.
• Potential eligibility for a performance-based bonus tied to individual and organizational performance.
• Comprehensive total rewards package supporting employee well-being.
• Remote work environment within the United States.
• Occasional travel of up to 15% may be required based on departmental needs.
• Opportunity to contribute to meaningful healthcare operations and initiatives affecting members, providers, and clinical teams.
• Collaborative environment with opportunities to work across clinical, operational, analytical, and cross-functional teams.

How Jobgether Works We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team.

We appreciate your interest and wish you the best!

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