Manager Utilization Management

 
Position: Manager Utilization Management

Job ID: 163273

Location: US-TX-Houston

Department: UTILIZATION MGMT - ADMIN

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 9a - 6p, M-F

About Texas Children's Hospital

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 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org. At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for all of our patients and families that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.   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.

Summary:

We are searching for a Manager of Utilization Management -- someone who works well in a fast-paced setting. In this position, you will supervise staff and develop all the processes and procedures for Utilization Management intake, concurrent review, and processing of denial and appeals. You will also assess the quality of service of Utilization Management and all programs and processes.

Think you’ve got what it takes?



Responsibilities :

  • Oversee and develop the processes and procedures for Utilization Management unit of the health plan
  • Monitor and audit turnaround time, review weekly statistics, ensure quarterly audit activity completed as indicated in policy and procedure
  • Collaborate with Assistant Director and UM Medical Director in the planning and implementation process to support adherence to regulatory guidelines, TDI regulations, federal and legislative obligations, as well as contractual agreements
  • Implements the necessary revisions for internal processes and procedures to meet and satisfy all guidelines as indicated by outside auditors
  • Coordination of the denial process with UM Medical Director and Assistant Director
  • Collaborate with the Chief Medical Officers and the Medical Directors in the appeals process, including investigating the initial review and documentation for decision making as indicated by policy and procedures
  • Assess trends for future opportunity for improvement in utilization management
  • Provide quarterly reporting to HHSC and for the Clinical and Administrative Advisory Committee
  • Identify areas of inefficiency and facilitates/coordinates resolution inter/intra departmentally by acting as liaison between departments across the TCHP
  • Work in conjunction with other team members to determine resolution, by monitoring and evaluating efficiency of changes and by providing feedback to staff, departments, and the leadership team


Qualifications:

  • Bachelor’s degree in nursing required
  • RN license from the Texas Board of Nursing or the Nursing Licensure Compact required
  • 5 years’ experience in clinical and/or managed care required
  • 5 years’ experience in pediatrics preferred
  • Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.


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