Manager Utilization Management

At our company, our mission starts with our people. Guided by our HEART values of Humility, Excellence, Accountability, Respect, and Trust, we strive to create a workplace where teammates feel valued, supported, and empowered to do their best work every day. As Manager for Utilization Management, you’ll lead utilization management intake, concurrent review, denial, and appeals processes. You’ll develop effective procedures, oversee team performance, and help ensure services meet quality, regulatory, contractual, and operational standards.

Job Duties & 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

Qualifications

Bachelor’s degree in nursing required, or

Master’s degree in speech-language pathology, physical therapy, occupational therapy, or social work required

Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact required, or

Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board required, or

Texas Speech-Language Pathologist license required, or

Licensed Clinical Social Worker or Licensed Master Social Worker license issued by the Texas Behavioral Health Executive Council required

Three years of utilization management or prior authorization experience required

Two years of managed care experience with government-sponsored programs required

Two years of pediatric experience preferred

Job Duties & 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

Qualifications

Bachelor’s degree in nursing required, or

Master’s degree in speech-language pathology, physical therapy, occupational therapy, or social work required

Registered Nurse license issued by the Texas Board of Nursing or through the Nursing Licensure Compact required, or

Physical Therapist or Occupational Therapist license issued by the applicable Texas licensing board required, or

Texas Speech-Language Pathologist license required, or

Licensed Clinical Social Worker or Licensed Master Social Worker license issued by the Texas Behavioral Health Executive Council required

Three years of utilization management or prior authorization experience required

Two years of managed care experience with government-sponsored programs required

Two years of pediatric experience preferred

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.

To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.

Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.