Manager Utilization Management
About The Position
The Manager for Utilization Management leads utilization management intake, concurrent review, denial, and appeals processes. The role develops and oversees procedures, monitors team performance, and helps ensure services meet quality, regulatory, contractual, and operational standards. The position works with leadership, medical directors, internal departments, insurers, regulatory entities, providers, members, and claims teams to maintain effective processes and address utilization management needs. The company describes its workplace as guided by HEART values: Humility, Excellence, Accountability, Respect, and Trust, with an aim to ensure teammates feel valued, supported, and empowered.
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 is required: 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
- Develops and oversees utilization management processes and procedures for intake, concurrent review, denials, and appeals.
- Monitors turnaround times, reviews weekly statistics, and ensures quarterly audit activities are completed in accordance with established policies.
- Manages daily workloads, prioritizes assignments, and reviews staff productivity and quality results.
- Monitors appropriate use of utilization review criteria, Medicaid guidance, and internal decision-making standards.
- Partners with leadership to recruit, hire, retain, orient, evaluate, and develop qualified utilization management staff.
- Collaborates with leadership and medical directors to implement processes that support regulatory, accreditation, contractual, and legislative requirements.
- Implements revisions to internal procedures based on audit findings, regulatory changes, and external review requirements.
- Communicates process updates and required changes with internal departments, insurers, and regulatory entities.
- Coordinates denial processes with medical leadership and supports investigation and documentation for appeal decisions.
- Serves as a liaison for provider and member complaints, concerns, and accessibility issues.
- Identifies utilization management trends and opportunities for process improvement.
- Prepares internal and external reports, including required state, accreditation, licensing, and advisory committee reporting.
- Evaluates systems and data sources to support accurate reporting and code availability.
- Collaborates with claims teams to review authorization-related claim appeals.
- Facilitates cross-functional solutions to improve efficiency and represents utilization management needs on interdepartmental teams.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
