Clinical Operations Program Manager - Clinical Appeals

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 project management tools to support accountability, transparency, and timely decision-making.
• Support new business activities, market launches, operational transitions, and other implementation efforts by coordinating requirements, work flows, communications, testing support, training needs, and post-go-live follow-up.
• Perform source system validation and data verification to support audit responses, Participate in live regulatory audits and audit activities, Coordinate retrieval and validation of supporting documentation requested during audits, Validate operational work flows against documented policies and procedures.
• Analyze operational and regulatory UM and appeals data; review regulatory reports for completeness, accuracy, and compliance; validate report data against source systems, operational databases, and supporting documentation; identify reporting discrepancies, investigate root causes, and collaborate with business partners to implement corrective actions; support leadership with regulatory reporting analysis and submission readiness.
• Support action plans and work required for audit feedback, reporting trends, stakeholder feedback, and work flow performance to identify improvement opportunities and support corrective action or process improvement plans.
• Provide regular status reporting, program and project metrics, business decision documents, and ongoing communication to senior management, stakeholders, executive sponsors, and impacted business areas.
• Represent UM Operations and Clinical Appeals in intake, governance, prioritization, and cross-functional workgroups related to operational projects, market support, audit readiness, compliance needs, and process enhancements.
• Support oversight and coordination of vendor-related operational activities, including vendor onboarding, issue resolution, work flow integration, performance monitoring, and alignment with UM Operations and Clinical Appeals business needs.
• Manage and maintain program/project documentation, including SharePoint sites or document repositories, meeting materials, decision logs, project artifacts, and operational reference materials.
• Perform any other job related duties as requested.

Education and Experience:

• Bachelor's degree in nursing, business management or related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years of healthcare experience required
• Two (2) years of project management, program management, operational implementation, or cross-functional business support experience required
• Experience supporting Utilization Management or Clinical Appeals operations, market implementations, audit readiness, compliance activities, clinical systems, or healthcare payer operational projects preferred

Competencies, Knowledge and Skills:

• Proficiency with Microsoft Office tools, including Project, Word, PowerPoint, Excel, Visio, Teams, Outlook, etc.
• High attention to detail with exceptional accuracy in documentation and data validation
• Adaptability and flexibility in a rapidly changing regulatory and operational environment
• Demonstrated skills related to project management, workflow design, operational implementation, process improvement, and cross-functional coordination
• Skilled in interpretation of analytics and insights
• Excellent decision making/problem solving skills
• Exceptional interpersonal and relationship building skills
• Excellent critical listening and thinking skills
• Proven ability to effectively interact with all levels of the organization of management within and externally to the organization
• Excellent written and verbal communication skills
• Customer service oriented
• Ability to shape the approach to needed results and gain consensus of the approach
• Proven ability to prioritize work and team assignments to deliver projects on time, on budget, and meeting stakeholders’ expectations
• Ability to document, track, and manage business requirements, action items, risks, issues, decisions, and deliverables throughout the project lifecycle
• Knowledge of Utilization Management (UM) and/or Clinical Appeals
• Strong knowledge of the healthcare payer industry and knowledge of Medicaid and Medicare
• Ability to understand and implement regulatory and contractual requirements
• Knowledge of audit readiness, quality monitoring, regulatory compliance, market operations, Utilization Management or Clinical Appeals, and healthcare payer operational workflows
• Ability to analyze processes across multiple functional areas
• Ability to work independently and within a team environment
• Ability to review and implement evidence-based trends
• Ability to develop, prioritize and accomplish goals

Licensure and Certification:

• Clinical licensure required
• Registered Nurse (RN) license preferred
• Six Sigma Certification preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Up to 15% (occasional) travel based on the needs of the department may be required

Compensation Range

$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type

Salary

Competencies

Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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