Product Manager-Healthcare Clinical Lead

Infosys Helix is seekingaProduct Manager- Healthcare Clinical Lead for this growing team. The Clinical Lead oversees day-to-day 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, high-quality care across the continuum.

Key Responsibilities
Utilization Review & Clinical Review Oversight

• Conduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence-based 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 decision-making 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.

Service Authorization Management

• 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.

Care Management Integration

• 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.

Quality, Compliance & Accreditation

• 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.

Operational Leadership & Staff Support

• 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.

Provider & Cross-Functional Collaboration

• 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.

Data & Performance Monitoring

• 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.

Core Competencies

• Clinical decision-making & 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

Required Qualifications

• The candidate must be located within commuting distance ofTempe, AZor be willing to relocate to this area.This position may require travel in the US.
• Bachelor's degree or foreign equivalent required from 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.

Preferred Qualifications

• 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.

Along with competitive pay, as a full-time Infosys employee you are also eligible for the following benefits:

• 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.

Client-provided location(s): Tempe, AZ

Job ID: Infosys-145203BR

Employment Type: OTHER

Posted: 2026-03-06T18:43:53