Clinical Services Manager

POSITION SUMMARY

The Clinical Services Manager is responsible for overseeing daily operations related to Utilization Management (UM), Clinical Auditing, and quality improvement initiatives within the organization. This role provides operational and clinical leadership to ensure efficient authorization processes, compliance with CMS/DMHC/health plan requirements, audit readiness, and continuous improvement in clinical and operational performance.

The Clinical Services Manager collaborates closely with interdisciplinary departments including Case Management, Quality Management, Provider Relations, Claims, Compliance, and Information Technology to support organizational goals related to patient care, regulatory compliance, operational excellence, and value-based care initiatives.

Essential Duties and Responsibilities

Utilization Management Operations

• Oversee daily UM operations including prior authorization review workflows, referral management, and turnaround time (TAT) compliance.
• Monitor authorization queues to ensure compliance with CMS, DMHC, NCQA, and health plan regulatory requirements.
• Assist with development, implementation, and monitoring of UM policies, procedures, and workflows.
• Ensure timely processing of standard, urgent, and expedited authorization requests.
• Collaborate with Medical Directors and providers regarding medical necessity criteria and escalation processes.
• Monitor operational performance metrics including TAT compliance, productivity, denial trends, and authorization accuracy.
• Identify workflow inefficiencies and implement process improvement initiatives to enhance operational performance.
• Participate in implementation and optimization of UM technologies, automation tools, and reporting systems.

Clinical Audit and Compliance Oversight

• Oversee internal clinical audit activities related to UM, quality, and documentation compliance.
• Conduct routine audits to ensure adherence to regulatory requirements, internal policies, and health plan standards.
• Monitor corrective action plans (CAPs) and support departments in remediation activities.
• Prepare for external audits including CMS, health plan, NCQA, and delegated entity audits.
• Analyze audit findings and develop action plans to improve compliance and operational outcomes.
• Ensure accurate and complete clinical documentation supporting authorization and quality initiatives.
• Track audit trends and provide leadership reports with recommendations for process improvements.

Staff Leadership and Development

• Supervise and support UM nurses, coordinators, clinical auditors, and support staff.
• Monitor staff productivity, quality performance, and adherence to departmental standards.
• Provide ongoing education, coaching, and mentorship to staff.
• Conduct staff meetings, performance evaluations, and competency assessments.
• Support recruitment, onboarding, and training of clinical operations staff.
• Foster a collaborative and accountable team environment focused on quality and service excellence.

Regulatory and Quality Management

• Maintain knowledge of CMS, DMHC, NCQA, HIPAA, and health plan regulatory requirements.
• Support organizational quality improvement and value-based care initiatives.
• Collaborate with Quality Management and Case Management teams to improve patient outcomes and reduce avoidable utilization.
• Assist with policy and procedure development and annual regulatory review updates.
• Ensure compliance with delegated agreements and health plan performance standards.

Data Analysis and Reporting

• Review and analyze operational, audit, and utilization data to identify trends and opportunities for improvement.
• Develop and present reports, dashboards, and operational summaries to leadership.
• Monitor key performance indicators (KPIs) related to UM operations, audit outcomes, and compliance measures.
• Collaborate with analytics and IT teams to improve reporting capabilities and operational visibility.

Qualifications

Education

• Registered Nurse (RN) required.
• Bachelor of Science in Nursing (BSN) required; Master’s degree preferred.
• Current unrestricted California RN license required.

Experience

• Minimum 5 years of experience in Utilization Management, Clinical Operations, Quality, or Managed Care.
• Minimum 2 years of leadership or supervisory experience preferred.
• Experience with delegated medical groups, IPA/MSO environment, or health plans preferred.
• Experience with CMS, DMHC, NCQA, and health plan audits strongly preferred.

Knowledge and Skills

• Strong understanding of utilization management processes and regulatory requirements.
• Knowledge of managed care operations, clinical auditing, and quality improvement methodologies.
• Ability to analyze data and identify operational improvement opportunities.
• Strong leadership, organizational, and communication skills.
• Experience with UM platforms and electronic medical record systems preferred.
• Proficiency in Microsoft Office applications including Excel, Word, and PowerPoint.

Physical Requirements

• Prolonged periods of sitting and computer use.
• Ability to attend meetings and training sessions as required.

Work Environment

• Hybrid or office-based work environment depending on organizational needs.
• Fast-paced managed care and healthcare operations environment require multitasking and prioritization.