Director of Operations Excellence at HF Sinclair focused on leading sustainable operations and enhancing operational performance in refining processes. Overseeing strategic implementation and continuous improvement within the operations leadership team.
About the role
- Senior Manager overseeing Clinical Utilization Management operations at Healthfirst. Ensuring compliance and excellence in medical necessity reviews and service authorizations.
Responsibilities
- 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
Requirements
- 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 multidisciplinary clinical teams
- Strong analytical, organizational, and problem-solving skills
- Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across functions
- Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.
Benefits
- medical, dental and vision coverage
- incentive and recognition programs
- life insurance
- 401k contributions
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