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Job Summary

The Manager of Clinical Program Management and Vendor Performance will compile reporting related to the performance and continuous improvement of Utilization Management (UM), Care Management (CM) and vendor programs. This role collaborates across clinical, operational and analytic teams for all lines of business to ensure compliant and high quality member centered outcomes. The Manager supports program monitoring, reporting, vendor performance management, and execution of internal operational improvements and vendor oversight for compliance requirements.

Requirements

EDUCATION

Bachelor’s degree in healthcare administration, public health, social work or related field required.

Master’s degree in nursing preferred.

LICENSING/CERTIFICATION

Clinical licensure such as Registered Nurse (RN), Licensed Practice Nurse (LPN), and/or Social Work (SW) preferred.

Knowledge of Utilization Review Accreditation Commission (URAC) Utilization Management/Care Management standards preferred.

EXPERIENCE & KNOWLEDGE

Minimum seven (7) years' experience Utilization Management or Care Management OR applicable master’s with minimum five (5) years’ experience.

Minimum two (2) years’ leadership experience (team, role, and/or project management).

Minimum of two (2) years demonstrated experience in reporting or dashboarding for program management to track key performance indicators.

Experience managing or working with external vendors preferred.

Strong knowledge of Utilization Management or Care Management workflows, documentation standards, and care coordination processes.

Knowledge of Utilization Review Accreditation Commission (URAC) Utilization Management/Care Management standards preferred.

ESSENTIAL ABILITIES

Demonstrated critical thinking and sound judgment.

Ability to interpret performance data, identify trends, and develop actionable recommendations.

Ability to lead requirements development and collaborate with data team to develop reporting and dashboarding for program monitoring.

Skills

• Business Process Development • Critical Thinking • Cross-Functional Collaboration • Data Reporting • Documentations • Facilitation • Interpersonal Communication • Leadership • Microsoft Office • Organizational Compliance • Organizing • Prioritization • Relationship Management • Setting Performance Standards

Responsibilities

• Collaborates with analytics and business teams to maintain and improve dashboards and reporting tools. • Conducts research and assists with workflow assessments to support operational improvements. • Ensures program compliance with regulatory, contractual, and audit expectations, including Utilization Management/Care Management standards. • Facilitates recurring vendor meetings, prepares agendas, documents updates, and drives follow‑up actions. • Facilitates Utilization Management and Care Management Oversight Committee meetings and participates in Stakeholder Oversight Committee meetings to deliver UM and CM performance reporting. • Facilitates working sessions with stakeholders to resolve program and process challenges. • Identifies barriers to vendor or program performance and partners with internal teams and vendors to address and resolve issues. • Implements a quarterly vendor performance program for Utilization Management and Care Management programs, serving as the primary operational point of contact. • Monitors vendor adherence to Service Level Agreements (SLAs), Key Performance Indicators (KPIs), and contractual requirements and supports timely resolution of issues/complaints. • Prepares summaries of program performance, risks, and operational recommendations for leadership. • Reviews and analyzes internal and vendor program data to identify performance trends, risks, and improvement opportunities.

Certifications

Registered Nurse (RN) - Arkansas State Board of Nursing

Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular

ADA Requirements

1.1  General Office Worker, Sedentary, Campus Travel – someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.