Senior Manager, Utilization Management

The 1199SEIU National Benefit Fund is a well-established organization dedicated to supporting healthcare workers and improving healthcare programs for its members. As a non-bargaining entity operating with a commitment to service excellence, the Fund offers various employee benefits and maintains strong adherence to regulatory compliance and healthcare standards. The organization embraces a hybrid workplace model, providing flexibility and work-life balance for its team members. Operating with permanent, full-time positions, the Fund fosters an inclusive, dynamic work environment that promotes growth, development, and leadership within the healthcare sector.

This role is designed for a seasoned healthcare professional with extensive managerial and clinical experience, specifically in utilization management and case management within managed care organizations. The position requires a proactive leader who will manage the daily operations and workflows by supervising clinical and non-clinical staff who support utilization management, benefits coordination, and the appeals process. Collaborating closely with senior leaders such as the Director and Assistant Director, this role is instrumental in shaping strategic initiatives that improve both clinical outcomes and financial performance. The successful candidate will be responsible for evaluating and optimizing processes, eliminating inefficiencies, and making well-informed recommendations to senior leadership to enhance staff productivity and operational effectiveness.

The incumbent will coordinate activities across various clinical programs while ensuring compliance with federal regulations such as those mandated by the Department of Labor, as well as internal protocols including the Summary Plan Description and clinical policies and procedures. Effective communication and collaboration across departments are essential in troubleshooting, problem-solving, and maintaining excellent relationships with healthcare providers and Fund members. The role also includes participation in interdepartmental committees and leading internal audits to uphold quality assurance standards.

Moreover, the position entails a significant responsibility for staff development including clinical orientation, ongoing education, and training programs tailored to meet the evolving needs of the department. A continual assessment of clinical staff performance against internal and industry benchmarks ensures adherence to best practices. This leadership role demands excellent critical thinking, analytical skills, and the ability to work independently to make critical business and clinical decisions. Additional duties and projects may be assigned by management to support the organization's objectives and mission.