Operations Manager

5 hours ago

Quezon City, National Capital Region, Philippines De Castro Consulting Full time
Job Summary

The Operations Manager for Utilization Management (UM) is responsible for leading and overseeing day-to-day UM operations to ensure high-quality service delivery, regulatory compliance, and operational efficiency. This role partners closely with clinical leadership, internal teams, and client stakeholders to drive performance, optimize processes, and maintain adherence to industry standards and service-level agreements (SLAs).


Key Responsibilities
  • Oversee daily Utilization Management operations, ensuring compliance with SLAs, regulatory standards, and client requirements.
  • Lead, coach, and manage UM teams to achieve performance, quality, and productivity targets.
  • Develop, implement, and continuously improve UM workflows, policies, and process improvement initiatives.
  • Manage team performance, workforce planning, and resource allocation to support operational demands.
  • Collaborate with internal partners and client stakeholders to enhance service delivery and maintain accurate staffing levels.
  • Ensure adherence to HIPAA, CMS, NCQA, and other applicable regulatory and compliance requirements.
  • Monitor quality metrics, audit outcomes, and appeal trends, and implement corrective action plans as needed.
  • Support and oversee clinical appeals processes, ensuring timely, compliant, and evidence-based determinations.
  • Prepare and present operational reports, insights, and recommendations to leadership.

Education & Certification Requirements
  • Bachelor's Degree in Nursing (BSN or equivalent).
  • Active U.S. Registered Nurse (RN) license required.
  • Compact RN license preferred.

Work Experience Requirements
  • Minimum of one (1) year of experience in a managerial or supervisory role.
  • Strong working knowledge of medical necessity guidelines, including but not limited to MCG, InterQual, NCQA, and ODG.
  • Demonstrated experience managing teams handling clinical reviews and appeals.
  • Prior experience in Utilization Management, Care Management, or a related healthcare operations environment is highly preferred.

Span of Control
  • Directly manages approximately 1 to 100 team members, depending on program size and operational needs.

Compensation
  • Philippine RN Operations Manager Rate: PHP 150,000 per month or higher, based on experience and qualifications.
  • U.S. RN Operations Manager Rate: Up to PHP 180,000 per month, based on licensure and scope of responsibility.

Key Competencies
  • Strong leadership and people management skills
  • In-depth knowledge of Utilization Management processes and clinical guidelines
  • Excellent communication and stakeholder management abilities
  • Data-driven decision-making and performance management
  • High attention to detail and commitment to regulatory compliance

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