Clinical Operations Manager, Utilization Review

JOB SUMMARY The Operations Manager drives Dane Street’s Group Health division by aligning daily operational leadership with clinical excellence in a high-volume, fast-paced environment. This role exists to ensure the seamless execution of utilization and independent clinical reviews by providing hands-on direction, capacity management, and clinical guidance to a multidisciplinary team of UR Nurses, QA Specialists, and Customer Service Representatives. By bridging front-line operations with cross-functional leadership, this position directly impacts Dane Street’s reputation and business growth—consistently delivering on tight turnaround times, rigorous quality compliance, client-specific standards, and overall team productivity. Mission, Culture & Values At Dane Street, we believe exceptional employee experiences create exceptional client experiences. Our culture is built on collaboration, continuous improvement, accountability, and care. We care for our customers, we care for our employees, and we care for one another. Every team member plays an important role in creating an environment where people feel respected, supported, empowered to grow, and inspired to do meaningful work. What You’ll Do Operational & Clinical Leadership Lead day-to-day operations for the assigned Group Health division, ensuring appropriate workflow, staffing, prioritization, and timely completion of work. Oversee Utilization Review Nurses, Clinical Quality Assurance Specialists, Customer Service Representatives, and other assigned operational staff. Manage the end-to-end operational workflow, including referral intake, clinical review preparation, quality assurance, client communication, and case completion. Serve as a clinical and utilization review subject matter resource for the team, providing guidance on clinical review workflows, utilization management principles, and complex or unusual case scenarios. Provide first-line support for clinical and process questions from clinical and non-clinical staff, escalating to Medical Director or senior clinical leadership when appropriate. Ensure operational and clinical processes align with client requirements, internal procedures, applicable regulatory requirements, and established utilization management workflows. Support new client implementations, volume expansions, and changes in client requirements. Lead the team through changing priorities, workflow demands, and business needs while maintaining service and quality expectations. Performance & KPI Management Monitor and manage key performance indicators, including turnaround time, productivity, quality, service levels, and client-specific performance requirements. Use operational data and reporting to identify trends, capacity constraints, performance gaps, and opportunities for improvement. Establish clear individual and team performance expectations and ensure accountability for established goals. Provide ongoing coaching, feedback, and performance management to team members. Develop and oversee corrective action or performance improvement plans when appropriate. Conduct timely and constructive performance evaluations. Recognize and develop high-performing team members and support succession and professional development opportunities. Provide leadership with regular updates regarding operational performance, staffing, capacity, risks, and improvement initiatives. Quality, Training & Process Improvement Partner with Quality Assurance, Training, and clinical leadership to maintain consistent, high-quality clinical review processes. Monitor quality trends and identify recurring clinical, operational, or knowledge gaps. Provide clinical and operational guidance to address identified trends and improve team performance. Partner with Training and Quality leadership to develop education, reference materials, and process improvements when recurring opportunities are identified. Support root cause analyses, corrective action plans, and client remediation efforts when needed. Identify workflow inefficiencies and implement process improvements designed to improve quality, productivity, consistency, and scalability. Promote adherence to client-specific guidelines, health plan requirements, internal policies, and applicable regulatory standards. Staffing & Capacity Planning Monitor referral volumes and workload throughout the day and adjust resources and priorities as needed to maintain turnaround time and service-level requirements. Evaluate staffing needs based on referral volume, productivity, client requirements, and anticipated growth. Proactively identify capacity risks and recommend staffing or operational adjustments. Partner with leadership and Human Resources to recruit, interview, select, and onboard qualified team members. Maintain appropriate staffing and coverage to support client requirements and fluctuations in referral volume. Support workforce planning associated with new business, client growth, and changes in operational scope. Client & Cross-Functional Partnership Support timely resolution of client questions, escalations, and operational concerns. Partner with Account Management and leadership to address client needs and maintain strong service performance. Collaborate with Medical Directors, Training, Quality Assurance, Network Management, Human Resources, Finance, IT, Business Analytics, and other departments to support operational objectives. Communicate operational risks, trends, and resource needs proactively to leadership. Participate in client and internal meetings as needed to provide operational and clinical expertise. Other duties Requirements What Makes This Role Successful: Success as an Operations Manager at Dane Street means running a predictable, high-performing Group Health division where clinical accuracy and operational speed coexist without compromising each other. What Your First 90 Days May Look Like: Days 1–30: Discover, Shadow & Build Baselines Goal: Understand the current operational landscape, workflows, tools, and team capabilities without making drastic changes. Operational Learning: Shadow end-to-end workflows (referral intake, clinical review prep, QA, case completion) to map the daily lifecycle of a review. Clinical & Client Immersion: Review client-specific guidelines, SLA commitments, regulatory requirements, and standard operating procedures (SOPs). Team Engagement: Conduct 1-on-1s with all direct reports (UR Nurses, QA, Customer Service) to understand individual responsibilities, workload pain points, and current support gaps. Metric Baselines: Review historical operational data (turnaround times, productivity, quality scores, error trends) to establish baseline understanding. Partnership Building: Connect with key cross-functional peers in QA, Training, HR, Account Management, and Medical Leadership to establish communication channels. Days 31–60: Evaluate, Coach & Optimize Daily Execution Goal: Transition from learning to active leadership, performance tracking, and intraday capacity management. Active KPI Ownership: Take full ownership of daily/weekly performance monitoring (TAT, productivity, quality metrics). Intraday Volume & Capacity Management: Actively monitor daily referral influx, reallocating team resources dynamically to prevent bottlenecking or missed SLAs. Performance Management & Coaching: Initiate regular coaching cycles based on quality and productivity data. Identify knowledge or skill gaps and partner with Training/QA to address them. Clinical Leadership: Serve as the primary first-line resource for process and clinical questions from the team, establishing clear escalation paths to Medical Directors for complex cases. Workflow Audit: Identify obvious operational friction points, duplicate steps, or communication gaps across intake, review, and QA. Days 61–90: Scale, Refine & Drive Continuous Improvement Goal: Implement sustainable process refinements, lead client/volume adjustments, and drive long-term operational consistency. Process Improvement: Execute targeted workflow enhancements or updated reference materials to resolve recurring error trends or inefficiency bottlenecks. Accountability & Growth: Establish formal performance improvement plans (PIPs) where needed, while recognizing top performers and identifying succession candidates. Client & Implementation Readiness: Actively support any incoming client implementations, volume expansions, or service scope changes without sacrificing standard division SLAs. Strategic Reporting: Deliver comprehensive operational updates to senior leadership detailing performance trends, staffing forecasting, capacity risks, and proactive recommendations. EDUCATION/CREDENTIALS: Active, unrestricted Registered Nurse (RN) license required. Bachelor’s degree in Nursing, Healthcare Administration, Business Administration, or a related field preferred. Must Haves: Utilization Review/Utilization Management experience required. Healthcare operations leadership or people-management experience in a fast-paced, high-volume environment required. Demonstrated experience managing operational KPIs, including productivity, quality, turnaround time, and service-level performance required. Demonstrated ability to serve as a clinical and utilization management subject matter resource for clinical and non-clinical teams. Experience leading multidisciplinary teams that include clinical and non-clinical staff. Strong working knowledge of medical necessity review, utilization management principles, and healthcare payer operations. Experience coaching employees, managing performance, and developing high-performing teams. Preferred Qualifications: Health plan, managed care, or payer experience strongly preferred. Experience with prior authorization, medical necessity review, appeals, and/or independent review services preferred. Experience managing remote teams preferred. Experience supporting client implementations, operational growth, or rapidly changing referral volumes preferred. WORKING CONDITIONS/PHYSICAL DEMANDS: Any lifting, bending, traveling, etc. required to do the job duties listed above. Long periods of sitting and computer work. Why Join Dane Street? Collaborative remote culture Professional growth opportunities Meaningful work supporting the healthcare industry Comprehensive benefits Great Place to Work Certified since 2021 Commitment to employee development WORK FROM HOME TECHNICAL REQUIREMENTS: Reliable high-speed internet service capable of supporting a fully remote work environment. Ability to maintain a secure and uninterrupted remote workspace in accordance with company requirements. Equal Opportunity Statement: At Dane Street, caring for people is at the heart of what we do. We are committed to creating an inclusive workplace where every employee feels respected, valued, and empowered to contribute. We provide equal employment opportunities to all applicants and employees and make employment decisions based on qualifications, merit, business needs, and without regard to race, color, religion, sexual orientation, gender identity or expression, national origin, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law. This job description is subject to change at any time. Benefits Join our team at Dane Street and enjoy a comprehensive benefits package designed to support your well-being and peace of mind. We offer a range of benefits including medical, dental, and vision coverage for you and your family. Additionally, we offer voluntary life insurance options for you, your spouse, and your children. We also offer other voluntary benefits which include hospital indemnity, critical illness, accident indemnity, and pet insurance plans. Employees receive basic life insurance, short-term disability, and long-term disability coverage at no cost. Our generous paid time off policy ensures you have time to relax and recharge, while our 401k plan with a company match helps you plan for your future. Apple equipment and a media stipend are provided for remote workspace. ABOUT DANE STREET: A fast-paced, Inc. 500 Company with a high-performance culture, is seeking insightful forward-thinking professionals. We process over 200,000 insurance claims annually for leading national and regional Workers’ Compensation, Disability, Auto, and Group Health Carriers, Third-Party Administrators, Managed Care Organizations, Employers, and Pharmacy Benefit Managers. We provide customized Independent Medical Exams and Peer Review programs that assist our clients in reaching the appropriate medical determination as part of the claims management process.