Clinical Operations Program Manager - Clinical Appeals

About this role

Job Summary:

The Clinical Operations Program Manager – UM Operations & Clinical Appeals is responsible for managing and coordinating operational projects or initiatives that support Utilization management (UM) and/or Clinical Appeals, market readiness activities, workflow improvements, activities that promote regulatory compliance, audit readiness, reporting accuracy, cross functional deliverables and continuous process improvement across Clinical Appeals and UM operations.


Essential Functions:

• Manage and prioritize operational projects, market support activities, Clinical Appeals or UM support needs, audit-related deliverables, compliance initiatives, work flow improvements, and system/process enhancement requests to ensure timely completion and alignment with business needs.
• Support successful delivery of Utilization Management and Clinical Appeals operational initiatives through project planning, work flow development, implementation coordination, stakeholder engagement, and post-implementation support.
• Partner with market leadership, UM Operations, and Clinical Appeals stakeholders to support new market implementations, product changes, operational readiness, issue resolution, and ongoing market-specific needs.
• Collaborate with Training and Auditing teams to support UM and Clinical Appeals audit tools, audit readiness, process documentation, quality monitoring, trend identification, and remediation planning.
• Support compliance-related activities by tracking regulatory and contractual requirements, coordinating updates to UM and Clinical Appeals work flows and documentation, monitoring risks, and escalating barriers that may impact operational appeals, or timeliness standards.
• Coordinate with internal stakeholders to ensure project requirements, reporting needs, process changes, and system impacts are clearly defined and appropriately prioritized.
• Maintain project plans, action logs, issue trackers, status updates, and other proj...