Manager Utilization Management

Texas Children's Hospital•Bellaire, TX

19h

About The Position

The Manager for Utilization Management leads utilization management intake, concurrent review, denial, and appeals processes. The role develops effective procedures, oversees team performance, and helps ensure services meet quality, regulatory, contractual, and operational standards. The manager works with leadership, medical directors, internal departments, insurers, regulatory entities, providers, members, and claims teams to support compliant and efficient operations, accurate reporting, and process improvement.

Requirements

Bachelor’s degree in nursing, or a master’s degree in speech-language pathology, physical therapy, occupational therapy, or social work.
One of the following licenses: Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact; Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board; Texas Speech-Language Pathologist license; or Licensed Clinical Social Worker or Licensed Master Social Worker license issued by the Texas Behavioral Health Executive Council.
Three years of utilization management or prior authorization experience.
Two years of managed care experience with government-sponsored programs.

Nice To Haves

Two years of pediatric experience.

Responsibilities

Develop and oversee utilization management processes and procedures for intake, concurrent review, denials, and appeals.
Monitor turnaround times, review weekly statistics, and ensure quarterly audits are completed according to established policies.
Manage daily workloads, prioritize assignments, and review staff productivity and quality results.
Monitor the appropriate use of utilization review criteria, Medicaid guidance, and internal decision-making standards.
Partner with leadership to recruit, hire, retain, orient, evaluate, and develop qualified utilization management staff.
Collaborate with leadership and medical directors to implement processes supporting regulatory, accreditation, contractual, and legislative requirements.
Revise internal procedures based on audit findings, regulatory changes, and external review requirements.
Communicate process updates and required changes to internal departments, insurers, and regulatory entities.
Coordinate denial processes with medical leadership and support investigation and documentation for appeal decisions.
Serve as a liaison for provider and member complaints, concerns, and accessibility issues.
Identify utilization management trends and opportunities for process improvement.
Prepare internal and external reports, including required state, accreditation, licensing, and advisory committee reports.
Evaluate systems and data sources to support accurate reporting and code availability.
Collaborate with claims teams to review authorization-related claim appeals.
Facilitate cross-functional solutions to improve efficiency and represent utilization management needs on interdepartmental teams.