Manager, Medical Management and Regulatory Operations - Remote

UnitedHealth Group•Pearland, TX

3d•$18 - $32•Remote

About The Position

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation’s leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together. The Referral Navigator Supervisor is responsible for the day-to-day supervision, coordination, and operational performance of the Referral Navigator Department, including Home Health, Durable Medical Equipment (DME), Incomplete Referrals, Closed the Loop activities, authorization support functions, and other assigned Medical Management operations. This is a working supervisor position that actively participates in production activities while providing leadership, guidance, coaching, and operational support to Referral Navigators and, when applicable, Team Leads. The Supervisor is responsible for ensuring quality, productivity, timeliness, customer service, regulatory compliance, and achievement of departmental goals through effective workload management and staff development. This position is expected to exercise sound judgment, critical thinking, and operational problem-solving skills to identify practical solutions, improve workflow efficiency, and resolve operational issues independently whenever possible, escalating only those matters requiring higher-level leadership involvement. If you are located in TX, you will have the flexibility to work remotely as you take on some tough challenges.

Requirements

Graduate from accredited nursing program
Registered Nurse or Licensed Vocational Nurse with state of Texas privileges
6+ years as a licensed vocational nurse (LVN) or Registered Nurse (RN)
4+ years of experience working within authorization modules, clinic charting systems, claims processing systems, or other operational areas of managed care
2+ years of management or supervisory experience in a managed care setting (physician office or hospital setting health plan, ACO, or other managed care setting)
Knowledge of medical terminology, coding, COB payment, and prior authorization processes
Demonstrate a working knowledge of industry standards processing
Alpha/numeric data entry and advanced PC literacy
Understanding of Health plan benefits and financial obligation interpretation
Proven excellent verbal communication and time management skills
Proven excellent interdepartmental coordination and communication

Nice To Haves

3+ years of Kelsey-Seybold experience
Experience with precertification and/or utilization management
Benefit interpretation experience
Knowledge of CPT & ICD 10 Coding methodologies and billing
Knowledge of insurance payer specific prior authorizations requirements preferred
Solid knowledge of HMO, PPO, and POS plan types
Solid knowledge of Medicare and commercial health plans

Responsibilities

Provides direct supervision, leadership, coaching, and support for Referral Navigator staff and, when applicable, Team Lead personnel
Functions as a working supervisor by maintaining an active production workload while supporting daily departmental operations
Oversees operational activities related to Home Health, Durable Medical Equipment (DME), Incomplete Referrals, Closed the Loop processes, authorization support functions, and other assigned Medical Management workflows
Monitors work queues, inventory levels, staffing resources, production metrics, and operational performance indicators to ensure departmental goals are achieved
Provides guidance and support to staff regarding workflow processes, payer requirements, referral coordination, problem resolution, and customer service expectations
Coordinates daily workload assignments, queue balancing, staffing coverage, and operational priorities to support service level expectations
Participates in rotational phone queue coverage and ensures staff compliance with phone performance and customer service expectations
Conducts onboarding, training, coaching, mentoring, and performance development activities for assigned staff
Collaborates with clinics, providers, facilities, home health agencies, utilization management teams, medical reviewers, and operational partners to support efficient progression of member care requests
Promotes accountability, ownership, teamwork, professionalism, and service excellence throughout the department
Ensures adherence to organizational policies, departmental procedures, accreditation standards, regulatory requirements, and payer-specific guidelines
Monitors quality performance through audits, case reviews, documentation reviews, and quality monitoring activities
Identifies quality concerns, process deficiencies, training opportunities, compliance risks, and operational issues and implements corrective actions as appropriate
Ensures accurate, timely, and audit-ready documentation of referral activities, communications, and operational actions
Supports implementation of departmental policies, workflow changes, quality initiatives, and corrective action plans
Conducts performance monitoring and provides feedback, coaching, and development opportunities to improve quality and consistency of work
Ensures staff maintain compliance with productivity, quality, documentation, and customer service expectations
Oversees daily operational performance to ensure referrals, home health requests, DME requests, authorization support activities, and Closed the Loop functions are completed within established turnaround times
Monitors aging inventories, pending requests, service levels, and operational workloads to identify and address delays before they impact patient care or customer service
Ensures timely follow-up on provider inquiries, clinic concerns, outstanding requests, and unresolved operational issues
Prioritizes departmental resources and workload distribution to maximize efficiency and support achievement of productivity and service goals
Holds staff accountable for meeting productivity standards, turnaround time expectations, attendance requirements, and operational commitments
Develops and implements workflow improvements that enhance efficiency, reduce delays, and improve overall departmental performance
Identifies opportunities for process improvement, workflow standardization, automation, and operational efficiency enhancements
Utilizes critical thinking, sound judgment, and available resources to resolve routine operational challenges independently before seeking leadership intervention
Researches operational issues, develops recommendations, and implements solutions designed to improve productivity, quality, member experience, and provider satisfaction
Assists leadership with reporting, staffing assessments, project implementation, operational planning, and departmental initiatives
Supports testing, implementation, and optimization of systems, workflows, and operational tools
Serves as a departmental resource for operational guidance, workflow interpretation, and problem resolution
Performs other duties as assigned to support departmental and organizational objectives