Clinical Operations Program Manager--UM Operations

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--UM Operations based in United States. This role leads operational programs and initiatives supporting Utilization Management (UM) and Clinical Appeals within a complex healthcare environment. You will coordinate market readiness, workflow improvements, compliance activities, audit preparation, reporting accuracy, and cross-functional deliverables. The position combines program management with operational analysis, stakeholder coordination, and continuous process improvement. You will work closely with clinical, operational, training, auditing, compliance, technology, and business teams to drive effective implementation and issue resolution. The role also provides visibility with senior leaders and executive stakeholders through program reporting, metrics, and decision support. It is an opportunity to make a meaningful impact on healthcare operations while strengthening regulatory readiness and member-focused processes.

Accountabilities You will manage and coordinate projects across UM and Clinical Appeals, ensuring operational initiatives, market implementations, compliance requirements, and process improvements are delivered accurately and on time.

• Manage and prioritize operational projects, market support activities, UM and Clinical Appeals needs, audit deliverables, compliance initiatives, workflow improvements, and system or process enhancement requests.
• Plan and coordinate UM and Clinical Appeals initiatives, including workflow development, implementation, stakeholder engagement, testing, and post-implementation support.
• Partner with market leadership and operational stakeholders on new market implementations, product changes, operational readiness, issue resolution, and market-specific requirements.
• Collaborate with Training and Auditing teams on audit tools, documentation, quality monitoring, trend identification, remediation planning, and audit readiness.
• Track regulatory and contractual requirements and coordinate updates to workflows and documentation while monitoring risks and escalating barriers that could affect appeals or timeliness standards.
• Define and prioritize project requirements, reporting needs, process changes, and system impacts with cross-functional stakeholders.
• Maintain project plans, action logs, issue trackers, status reports, decision logs, and other project management documentation.
• Support new business activities, market launches, operational transitions, and implementations by coordinating requirements, workflows, communications, testing, training, and post-go-live activities.
• Perform source-system validation and data verification for audit responses and regulatory activities, including retrieving and validating supporting documentation.
• Participate in live regulatory audits and validate operational workflows against documented policies and procedures.
• Analyze UM and appeals data and regulatory reports for completeness, accuracy, and compliance; investigate discrepancies and root causes and coordinate corrective actions.
• Support leadership with regulatory reporting analysis, submission readiness, program metrics, and business decision materials.
• Develop and monitor action plans based on audit findings, reporting trends, stakeholder feedback, and workflow performance.
• Provide regular program and project updates to senior management, executive sponsors, stakeholders, and impacted business areas.
• Represent UM Operations and Clinical Appeals in governance, prioritization, intake, and cross-functional workgroups.
• Coordinate vendor-related operational activities, including onboarding, issue resolution, workflow integration, and performance monitoring.
• Manage SharePoint sites, document repositories, meeting materials, project artifacts, and operational reference documentation.
• Contribute to continuous improvement initiatives and other job-related projects as needed.

Requirements The ideal candidate combines healthcare industry knowledge with strong program management, analytical, communication, and problem-solving capabilities. You should be comfortable navigating regulated environments, coordinating complex cross-functional initiatives, and managing detailed documentation and data validation.

• Bachelor's degree in Nursing, Business Management, or a related field required; equivalent relevant experience may be accepted in lieu of 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 with Utilization Management or Clinical Appeals, market implementations, audit readiness, compliance, clinical systems, or healthcare payer operations preferred.
• Clinical licensure required; Registered Nurse (RN) license preferred.
• Six Sigma certification preferred.
• Strong knowledge of Utilization Management and/or Clinical Appeals.
• Strong understanding of the healthcare payer industry, including Medicaid and Medicare.
• Knowledge of audit readiness, quality monitoring, regulatory compliance, market operations, and healthcare payer workflows.
• Ability to interpret and analyze operational data, identify trends, validate reporting, and translate insights into action.
• Demonstrated ability in project management, workflow design, operational implementation, process improvement, and cross-functional coordination.
• Strong attention to detail and exceptional accuracy when reviewing documentation and validating data.
• Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, and Outlook.
• Excellent written and verbal communication, critical thinking, active listening, interpersonal, and relationship-building skills.
• Strong decision-making and problem-solving abilities, with the judgment to shape approaches and build stakeholder consensus.
• Ability to prioritize competing assignments and deliver projects on time, within budget, and in line with stakeholder expectations.
• Ability to document and manage requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle.
• Ability to understand and implement regulatory and contractual requirements.
• Ability to work independently and collaboratively across multiple functional areas and organizational levels.
• Adaptable and flexible when working in changing regulatory and operational environments.
• Strong ownership, customer-service orientation, and ability to develop, prioritize, and accomplish goals.
• Willingness to review and apply evidence-based trends to operational improvement initiatives.

Benefits

• Base salary range of $113,000–$197,700 per year.
• Eligibility for a bonus tied to company and individual performance.
• Remote, full-time position.
• Comprehensive total rewards package supporting employee well-being.
• Occasional travel of up to 15% based on departmental needs.
• Opportunity to work across Utilization Management, Clinical Appeals, healthcare operations, compliance, and process improvement.
• Exposure to senior management, executive sponsors, and cross-functional business 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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