About this role

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

Qualifications