Manager Utilization Management

Position: Manager Utilization Management

Job ID: 400439

Location: US-TX-Houston

Department: Utilization Mgmt - Admin

Talent Area: Registered Nurse

Full/Part Time: Full time

Regular/Temporary: Regular

Shift: 9am-6pm

About Texas Children's Hospital

Since 1954, Texas Children’s has been leading the charge in patient care, education and research to accelerate health care for children and women around the world. When you love what you do, it truly shows in the smiles of our patient families, employees and our numerous accolades such as being consistently ranked as the best children’s hospital in Texas, and among the top in the nation by U.S.News & World Report as well as recognition from Houston Business Journal as one of this city’s Best Places to Work for ten consecutive years.

Texas Children’s comprehensive health care network includes our primary hospital in the Texas Medical Center with expertise in over 40 pediatric subspecialties; the Jan and Dan Duncan Neurological Research Institute (NRI); the Feigin Center for pediatric research; Texas Children’s Pavilion for Women, a comprehensive obstetrics/gynecology facility focusing on high-risk births; Texas Children’s Hospital West Campus, a community hospital in suburban West Houston; and Texas Children’s Hospital The Woodlands, a second community hospital opening in 2017. We have also created the nation’s first HMO for children, established the largest pediatric primary care network in the country and a global health program that is channeling care to children and women all over the world. Texas Children’s Hospital is also academically affiliated with Baylor College of Medicine, one of the largest, most diverse and successful pediatric programs in the nation.

To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at


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?


  • 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.



  • 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

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