Utilization Review Clinical Supervisor, El Paso Health

El Paso Health • El Paso, TX

10d

About The Position

Oversees day-to-day medical necessity, authorization, and clinical review functions within the Health Services Department. Ensures Utilization Review Associates consistently apply established medical policies, clinical guidelines, and plan benefit criteria within their scope of licensure. Coordinates with Case Management to support seamless care transitions and with the Pharmacy Department to streamline medication-related authorizations and help ensure members receive appropriate, high-quality care in a timely manner.

Oversees utilization review, compliance, and cross-departmental coordination across all health plan lines of business, including Medicaid (STAR, STAR+PLUS), CHIP (CHIP, CHIP Perinate), Medicare and Duals (D-SNP, Medicare Advantage, Medicare Dual Aligned), and Commercial and Specialty lines (Preferred Administrators, HCO). Directly supervises Clinical Reviewers (RNs/LVNs) to ensure timely, accurate, and compliant coverage decisions, and provides oversight to Utilization Review Assistants who support workflows, reporting, and authorization-related clerical duties.

Requirements

• At least one year of clinical supervisory, lead, or charge nurse experience.
• Deep operational knowledge of MCG and InterQual clinical guidelines, CMS regulations, Texas Medicaid rules, HHSC requirements, and TDI regulations.
• Active and unrestricted license to practice as a Registered Nurse (RN) in Texas.
• Bachelor of Science in Nursing (BSN).
• Excellent oral and written communication and interpersonal skills.
• Proficiency in Microsoft Windows, Word, Excel, and PowerPoint, with strong analytical and data management skills.
• Proficiency in utilization management principles, conflict resolution, creative problem-solving, and/or group facilitation techniques.
• Knowledge of state regulations, compliance standards, and network guidelines.
• Ability to manage multiple priorities in a fast-paced environment and provide effective, professional support to teams.
• Sensitivity to cultural diversity and ability to work with diverse populations; self-motivation and willingness to take responsibility for clinical care.
• Strong time management and prioritization skills, with the ability to complete assignments and interact effectively with supervisors, members, and community providers.

Nice To Haves

• Experience with utilization review/utilization management within a managed care organization (MCO) environment.

Responsibilities

• Oversee day-to-day medical necessity, authorization, and clinical review functions in the Health Services Department.
• Ensure Utilization Review Associates consistently apply medical policies, clinical guidelines, and plan benefit criteria within their scope of licensure.
• Coordinate with Case Management to support seamless care transitions.
• Coordinate with the Pharmacy Department to streamline medication-related authorizations.
• Oversee utilization review, compliance, and cross-departmental coordination across all health plan lines of business.
• Directly supervise Clinical Reviewers (RNs/LVNs) to ensure timely, accurate, and compliant coverage decisions.
• Oversee Utilization Review Assistants’ workflows, reporting, and authorization-related clerical duties.
• Manage clinical authorization workflows and oversee utilization reviewers’ productivity.
• Interpret health plan benefits for community providers and support accurate, data-driven medical necessity decisions.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager