Sr Manager, Clinical UM Operations - Automation

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:

• Partner with UM Directors and the Vice President to advance the design and implementation of future-state UM workflows, processes, and operating practices that support modernization, standardization, and scalability.
• Collaborate with UM leadership, external consultants, project management, technology, and vendor teams to support execution of UM transformation priorities and translate operational needs into practical solutions.
• Contribute UM operational expertise to transformation initiatives, helping identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams.
• Support operational readiness and adoption of new technologies, workflows, and capabilities by partnering with leaders and project teams on stakeholder engagement, training, implementation, and stabilization.
• Apply experience with AI, automation, and other emerging technologies to help identify and advance opportunities that improve UM operations while ensuring solutions align with clinical workflows, compliance, audit requirements, and user needs.
• 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…