Business Systems Clinical Platform Manager (Remote)

About the Role

This position manages all key aspects of systems operations, including configuration setup, system and integration testing, production issues triage and resolution, and interface monitoring. The Manager provides accountability for the day-to-day operational health, system stability, and continuous execution of core clinical applications in a changing healthcare environment. This role focuses specifically on optimizing end-to-end business processes within Utilization Management, Case Management, and Appeals & Grievances. The Manager ensures systems optimization and availability in a mission-critical, high-availability environment. Candidates must be located in the Maryland, Washington, DC, or Northern Virginia (DMV) area and will be expected to come into a CareFirst location periodically for meetings, training, and other business-related activities.

Responsibilities

• Provide deep subject matter expertise in all areas of Utilization Management (UM), including pre-service, concurrent review, and inpatient management, with a focus on optimizing end-to-end business processes (e.g., data, metrics, information technology) to support effective task and goal accomplishment.
• Accountable for the day-to-day operations of GuidingCare, MCG, and other clinical applications, ensuring seamless support for core plan functions including UM, Case Management (CM), and Appeals & Grievances (A&G).
• Directly manage a team of 8-12 professionals, overseeing the daily pipeline of system updates, configuration changes, system enhancements, and User Acceptance Testing (UAT) cycles.
• Drive timely project delivery and handle high operational volume by providing clear, actionable direction and oversight to configuration and testing teams.
• Serve as the operational bridge between clinical stakeholders and technical configuration teams, independently prioritizing daily work based on business impact and medical management goals.
• Develop, maintain, and report on operational dashboards to ensure leadership has transparent tracking of system health, task execution, and team throughput.
• Manage core administrative and financial responsibilities, including accurate vendor invoice processing and budget tracking to support ongoing clinical operations.
• Serve as the subject matter expert and representative for the clinical products team across corporate initiatives and enterprise-wide projects.
• Maintain a strong working knowledge of the FACETS claims-to-authorization matching workflow and utilize this knowledge to identify and resolve operational and system gaps.
• Build trusted relationships within CareFirst to deepen subject-matter expertise, find opportunities to synchronize with core operations, and ensure close coordination with the central team.
• Identify opportunities for synergies to improve task execution across the organization.
• Ensure successful completion of day-to-day changes, corporate initiatives, and other projects by managing team and/or matrixed resources for effective Systems Development Life Cycle (SDLC) activities, including request analysis, requirements documentation, acceptance testing, and implementation impact assessment.
• Direct and participate in planning sessions to align team operations and long-range goals with other department staff, IT, and clients.
• Develop and/or assist with project management plans for day-to-day changes, corporate initiatives, and other projects, including resource estimates, timeframes, cost/benefit ROI business cases, and budget development.
• Oversee corporate processes for systems change management, including request submission, review, validation, prioritization, scheduling, and status reporting.

Requirements

• Bachelor’s Degree in Business Administration or related field OR an additional 4 years of relevant work experience in lieu of a degree.
• 5 years of Business Analysis experience.
• 1 year of supervisory or progressive leadership experience.

Preferred Qualifications

• Certification in an applicable domain area.
• 5 years of experience in business development, operational technology support, Utilization Management (UM) operations, day-to-day clinical application management, Clinical Product Configuration, Health Plan Claims/Authorization workflows, or related healthcare consulting.
• Minimum of 3 years of operational leadership explicitly within Health Services, Medical Management, or Clinical Operations (Note: purely technical or traditional IT support backgrounds will not meet the requirements of this role).

Skills

• Proven ability to lead a large operational team (8-12 staff) and oversee defect triaging, release coordination, and production deployments.
• Demonstrated ability to independently translate clinical policies and business goals into daily operational execution, with a strong understanding of UM, CM, and A&G workflows.
• Effective knowledge of Utilization Management (UM) processes (pre-service, concurrent, inpatient) and applicable regulatory requirements (e.g., CMS, state mandates, accreditation standards).
• Proficient understanding of medical coding systems (CPT, ICD-10, HCPCS) and the annual code maintenance review cycle.
• Strong business acumen, including understanding of business goals, priorities, and evolving market trends.
• Exceptional communication skills, both verbal and written, for conveying complex ideas.
• Excellent project management, facilitation, and organizational skills.
• Strong relationship management and collaboration skills.
• Strategic thinker, problem solver, and collaborator who can drive engagement and discussions.
• Significant experience with MS Office (Excel, PowerPoint, Word).

Pay

Salary range: $120,400 - $223,493. The disclosed range has not been adjusted for geographic differentials. Compensation decisions depend on factors such as scope and responsibilities of the position, candidate’s work experience, education/training, internal peer equity, and market considerations. It is not typical for an individual to be hired at the top of the range.

Benefits

CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).