Product Manager-Healthcare Clinical Lead
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Job Location:
Monthly Salary:
Posted on:
2 days ago
Vacancies:
1 Vacancy
Job Summary
InfosysHelix is seekingaProductManager-HealthcareClinical Lead forthis growing Clinical Lead oversees daytoday operations of utilization management clinical reviews service authorization processes and care management functions for the health plan. This role provides clinical expertise ensures regulatory compliance supports staff development and drives appropriate highquality care across the continuum.
Utilization Review & Clinical Review Oversight
- Conduct and oversee utilization reviews (prospective concurrent and retrospective) using evidencebased criteria such as InterQual MCG CMS and state guidelines.
- Perform clinical reviews of inpatient outpatient specialty and ancillary services to determine medical necessity level of care and appropriateness.
- Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations.
- Ensure UM decisionmaking complies with federal/state regulations CMS requirements NCQA/URAC standards and timeliness expectations.
- Provide coaching to staff on documentation quality criteria selection and clinical justification.
- Oversee the intake triage and review of service authorization requests (e.g. DME home health specialty services behavioral health advanced imaging).
- Ensure timely processing of authorizations within regulatory and contractual turnaround times (TATs).
- Review complex cases requiring clinical expertise and determine approval modification or need for medical director review.
- Monitor volume trends authorization patterns and provider issues to identify process improvements.
- Support transitions of care coordination between UM and CM and continuity across inpatient and outpatient settings.
- Participate in interdisciplinary rounds addressing high-risk complex or high-cost cases.
- Provide guidance to Care Managers on clinical issues impacting utilization level of care or benefit coverage.
- Collaborate with Care Management to identify members requiring engagement in case disease or population health programs.
- Ensure compliance with CMS state Medicaid DOI and accreditation standards related to UM/CM (NCQA URAC).
- Conduct documentation audits and support corrective actions to maintain audit readiness.
- Assist in developing updating and implementing UM and CM policies workflows and clinical guidelines.
- Participate in regulatory audits readiness reviews and internal quality committees.
- Serve as a subject matter expert for clinical reviews UM criteria and service authorization workflows.
- Provide coaching training onboarding and daily support to nurses UM coordinators and CM staff.
- Review cases for quality accuracy completeness and compliance with organizational standards.
- Manage workload distribution address barriers and support issue resolution in real time.
- Collaborate with providers on clinical documentation requirements UM criteria and decision rationales.
- Work with network providers to reduce unnecessary utilization and facilitate timely transitions of care.
- Partner with internal teams (Pharmacy Behavioral Health CM Claims) to ensure seamless operations and problem resolution.
- Monitor UM metrics including:
- Concurrent review timeliness
- Appeals and overturn rates
- Authorization turnaround times
- Length of stay and readmission trends
- High-utilization outliers
- Use analytics to identify trends resource gaps and opportunities to optimize utilization and member outcomes.
- Clinical decisionmaking & critical thinking
- Knowledge of UM standards & clinical criteria
- Operational rigor & regulatory compliance
- Communication with members and providers
- Coaching mentoring and team leadership
- Workflow optimization & problem-solving
- Data-driven decision-making
- Collaboration across multidisciplinary teams
- The candidate must belocatedwithin commuting distanceofTempeAZor be willing torelocateto this position may require travelinthe US.
- Bachelors degree or foreign equivalentrequiredfrom an accredited institution. Will also consider three years of progressive experience in the specialty in lieu of every year of Education.
- 7 Yrs of Domain experience (Healthcare).
- 5 yrs of clinical experience in utilization management care management or clinical review roles within a health plan hospital or integrated delivery system.
- Active unrestricted RN license (or clinical licensure appropriate for UM e.g. LPN in some markets LCSW for integrated BH programs).
- Strong understanding of InterQual/MCG criteria medical necessity reviews and authorization processes.
- Knowledge of federal and state UM regulations CMS guidelines NCQA/URAC standards and HIPAA.
- Excellent clinical judgment communication and documentation skills.
- Certification in Case Management or Utilization Management (CCM ACM-RN CPUR CPHM).
- Experience with Medicare Advantage Medicaid Managed Care or Commercial health plans.
- Familiarity with UM and CM platforms (e.g. GuidingCare MHK HealthEdge TruCare CaseTrakker).
- Experience in provider relations audit support or process improvement initiatives.
- Medical/Dental/Vision/Life Insurance.
- Long-term/Short-term Disability.
- Health and Dependent Care Reimbursement Accounts.
- Insurance (Accident Critical Illness Hospital Indemnity Legal).
- 401(k) plan and contributions dependent on salary level.
- Paid holidays plus Paid Time Off.
The job entails sitting as well as working at a computer for extended periods of time. Should be able to communicate by telephone email or face to face. Travel may be required as per the job requirements.
About Us
Infosys is a global leader in next-generation digital services and consulting. We enable clients in more than 50 countries to navigate their digital transformation. With over four decades of experience in managing the systems and workings of global enterprises we expertly steer our clients through their digital journey. We do it by enabling the enterprise with an AI-powered core that helps prioritize the execution of change. We also empower the business with agile digital at scale to deliver unprecedented levels of performance and customer delight. Our always-on learning agenda drives their continuous improvement through building and transferring digital skills expertise and ideas from our innovation ecosystem.
Infosys provides equal employment opportunities to applicants and employees without regard to race; color; sex; gender identity; sexual orientation; religious practices and observances; national origin; pregnancy childbirth or related medical conditions; status as a protected veteran or spouse/family member of a protected veteran; or disability.
Required Experience:
IC
Key Skills
- Revenue Cycle Management
- HIPAA
- Healthcare Management
- PMBOK
- Microsoft Outlook
- Project Leadership
- Data Management
- Project Management
- Affiliate Marketing
- Project Management Software
- Supervising Experience
- Workday
About Company
Welcome to Infosys Careers for Experienced Professionals As a leading provider of next-generation consulting, technology and outsourcing solutions, we are dedicated to helping organizations in over 46 countries to renew their core and simultaneously innovate into new frontiers. Whilst ... View more
