Clinical Operations Manager, Utilization Review

JOB reputed company

The Operations Manager drives reputed company’s Group Health division by aligning daily operational leadership with clinical reputed company in a high-volume, fast-paced environment. This role exists to ensure the reputed company execution of utilization and independent clinical reviews by providing hands-on direction, reputed company management, and clinical guidance to a multidisciplinary team of UR Nurses, QA Specialists, and Customer Service Representatives. By reputed company reputed company-line operations with cross-functional leadership, this position directly impacts reputed company’s reputed company and business reputed company—consistently delivering on tight turnaround times, rigorous reputed company compliance, reputed company-specific standards, and overall team productivity.

Mission, reputed company; Values

At reputed company, we reputed company exceptional employee experiences create exceptional reputed company experiences. Our culture is reputed company on collaboration, reputed company improvement, accountability, and care.

We care for our customers, we care for our employees, and we care for one another. Every team member plays an important role in creating an environment where people feel respected, supported, empowered to grow, and inspired to do meaningful work.

reputed company

Operational & Clinical Leadership

• reputed company day-to-day operations for the assigned Group Health division, ensuring appropriate workflow, reputed company, prioritization, and reputed company completion of work.
• reputed company Utilization Review Nurses, Clinical reputed company Assurance Specialists, Customer Service Representatives, and other assigned operational staff.
• Manage the end-to-end operational workflow, including referral intake, clinical review preparation, reputed company assurance, reputed company communication, and case completion.
• Serve as a clinical and utilization review subject matter resource for reputed company, providing guidance on clinical review workflows, utilization management principles, and reputed company or unusual case scenarios.
• reputed company first-line support for clinical and process questions from clinical and non-clinical staff, escalating to Medical Director or senior clinical leadership reputed company appropriate.
• Ensure operational and clinical processes reputed company with reputed company requirements, internal procedures, applicable regulatory requirements, and established utilization management workflows.
• Support new reputed company implementations, volume expansions, and changes in reputed company requirements.
• reputed company reputed company through changing priorities, workflow demands, and business needs while maintaining service and reputed company expectations.

Performance & KPI Management

• Monitor and manage key performance indicators, including turnaround time, productivity, reputed company, service reputed company, and reputed company-specific performance requirements.
• Use operational data and reporting to identify trends, reputed company constraints, performance gaps, and opportunities for improvement.
• Establish reputed company individual and team performance expectations and ensure accountability for established goals.
• reputed company ongoing coaching, feedback, and performance management to team members.
• reputed company and reputed company corrective reputed company or performance improvement plans reputed company appropriate.
• Conduct reputed company and constructive performance evaluations.
• Recognize and reputed company high-performing team members and support succession and reputed company development opportunities.
• reputed company leadership with regular updates regarding operational performance, reputed company, reputed company, risks, and improvement initiatives.

reputed company, Training & Process Improvement

• Partner with reputed company Assurance, Training, and clinical leadership to maintain consistent, high-reputed company clinical review processes.
• Monitor reputed company trends and identify recurring clinical, operational, or knowledge gaps.
• reputed company clinical and operational guidance to address identified trends and improve team performance.
• Partner with Training and reputed company leadership to reputed company education, reference materials, and process improvements reputed company recurring opportunities are identified.
• Support reputed company cause analyses, corrective reputed company plans, and reputed company remediation efforts reputed company needed.
• Identify workflow inefficiencies and implement process improvements designed to improve reputed company, productivity, consistency, and scalability.
• Promote adherence to reputed company-specific guidelines, health plan requirements, internal policies, and applicable regulatory standards.

reputed company & reputed company Planning

• Monitor referral volumes and workload throughout the day and reputed company resources and priorities as needed to maintain turnaround time and service-level requirements.
• Evaluate reputed company needs based on referral volume, productivity, reputed company requirements, and anticipated reputed company.
• Proactively identify reputed company risks and recommend reputed company or operational adjustments.
• Partner with leadership and reputed company to recruit, interview, select, and reputed company reputed company team members.
• Maintain appropriate reputed company and coverage to support reputed company requirements and fluctuations in referral volume.
• Support workforce planning associated with new business, reputed company reputed company, and changes in operational reputed company.

reputed company & Cross-Functional Partnership

• Support reputed company reputed company of reputed company questions, escalations, and operational concerns.
• Partner with Account Management and leadership to address reputed company needs and maintain strong service performance.
• Collaborate with Medical Directors, Training, reputed company Assurance, Network Management, reputed company, Finance, IT, Business Analytics, and other departments to support operational objectives.
• Communicate operational risks, trends, and resource needs proactively to leadership.
• Participate in reputed company and internal meetings as needed to reputed company operational and clinical expertise.

Other duties

Requirements

What Makes This Role Successful:

reputed company as an Operations Manager at reputed company means running a predictable, high-performing Group Health division where clinical accuracy and operational speed coexist without compromising reputed company other.

What Your First 90 Days May Look Like:

Days 1–30: Discover, reputed company & Build Baselines

• Goal: Understand the reputed company operational landscape, workflows, tools, and team capabilities without making drastic changes.
• Operational Learning: reputed company end-to-end workflows (referral intake, clinical review prep, QA, case completion) to map the daily lifecycle of a review.
• Clinical & reputed company Immersion: Review reputed company-specific guidelines, SLA commitments, regulatory requirements, and reputed company operating procedures (SOPs).
• Team Engagement: Conduct 1-on-1s with reputed company reputed company reports (UR Nurses, QA, Customer Service) to understand individual responsibilities, workload pain points, and reputed company support gaps.
• Metric Baselines: Review historical operational data (turnaround times, productivity, reputed company scores, error trends) to establish baseline understanding.
• Partnership Building: reputed company with key cross-functional peers in QA, Training, HR, Account Management, and Medical Leadership to establish communication channels.

Days 31–60: Evaluate, reputed company & Optimize Daily Execution

• Goal: Transition from learning to reputed company leadership, performance tracking, and intraday reputed company management.
• reputed company KPI Ownership: Take full ownership of daily/weekly performance monitoring (TAT, productivity, reputed company metrics).
• Intraday Volume & reputed company Management: reputed company monitor daily referral reputed company, reallocating team resources dynamically to prevent bottlenecking or missed SLAs.
• Performance Management & Coaching: Initiate regular coaching cycles based on reputed company and productivity data. Identify knowledge or reputed company gaps and partner with Training/QA to address them.
• Clinical Leadership: Serve as the reputed company first-line resource for process and clinical questions from reputed company, establishing reputed company escalation paths to Medical Directors for reputed company cases.
• Workflow Audit: Identify reputed company operational friction points, duplicate steps, or communication gaps across intake, review, and QA.

Days 61–90: reputed company, Refine & reputed company reputed company Improvement

• Goal: Implement sustainable process refinements, reputed company reputed company/volume adjustments, and reputed company long-term operational consistency.
• Process Improvement: Execute targeted workflow enhancements or updated reference materials to reputed company recurring error trends or inefficiency bottlenecks.
• Accountability & reputed company: Establish formal performance improvement plans (PIPs) where needed, while recognizing top performers and identifying succession candidates.
• reputed company & Implementation Readiness: reputed company support any incoming reputed company implementations, volume expansions, or service reputed company changes without sacrificing reputed company division SLAs.
• Strategic Reporting: reputed company comprehensive operational updates to senior leadership detailing performance trends, reputed company forecasting, reputed company risks, and proactive recommendations.

EDUCATION/CREDENTIALS:

• reputed company, unrestricted Registered reputed company (RN) license required.
• Bachelor’s degree in Nursing, reputed company Administration, Business Administration, or a reputed company field preferred.

Must Haves:

• Utilization Review/Utilization Management experience required.
• reputed company operations leadership or people-management experience in a fast-paced, high-volume environment required.
• Demonstrated experience managing operational KPIs, including productivity, reputed company, turnaround time, and service-level performance required.
• Demonstrated ability to serve as a clinical and utilization management subject matter resource for clinical and non-clinical teams.
• Experience leading multidisciplinary teams that include clinical and non-clinical staff.
• Strong working knowledge of medical necessity review, utilization management principles, and reputed company payer operations.
• Experience coaching employees, managing performance, and developing high-performing teams.

Preferred Qualifications:

• Health plan, managed care, or payer experience strongly preferred.
• Experience with prior authorization, medical necessity review, appeals, and/or independent reputed company preferred.
• Experience managing reputed company preferred.
• Experience supporting reputed company implementations, operational reputed company, or rapidly changing referral volumes preferred.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work.

Why Join reputed company?

• reputed company remote culture
• reputed company reputed company opportunities
• Meaningful work supporting the reputed company industry
• Comprehensive benefits
• Great reputed company to Work Certified since 2021
• Commitment to employee development

WORK FROM HOME TECHNICAL REQUIREMENTS:

Reliable high-speed internet service capable of supporting a fully remote work environment.

Ability to maintain a secure and uninterrupted remote workspace in accordance with company requirements.

Equal Opportunity Statement:

At reputed company, caring reputed company is at the heart of reputed company do. We are committed to creating an inclusive workplace where every employee feels respected, valued, and empowered to contribute. We reputed company equal employment opportunities to reputed company applicants and employees and reputed company employment reputed company based on qualifications, reputed company, business needs, and without reputed company to race, reputed company, religion, sexual orientation, gender identity or reputed company, national reputed company, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.

This reputed company is subject to change at any time.

Benefits

reputed company at reputed company and enjoy a comprehensive benefits package designed to support your reputed company-being and peace of mind. We offer a reputed company of benefits including medical, dental, and reputed company coverage for you and your family. Additionally, we offer voluntary life insurance reputed company for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous reputed company time off policy ensures you have time to relax and reputed company, while our 401k plan with a company match helps you plan for your reputed company. reputed company equipment and a media stipend are provided for remote workspace.

ABOUT reputed company:

A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful reputed company-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, reputed company-Party Administrators, Managed Care Organizations, reputed company, and Pharmacy Benefit Managers. We reputed company customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.

Originally posted on Himalayas