Provides executive leadership, strategic direction, and comprehensive operational oversight for all Utilization Management functions, including inpatient utilization review, outpatient prior authorization, concurrent review, retrospective review, medical necessity determination, physician review processes, administrative utilization support, delegated health plan requirements, regulatory reporting, and related clinical and non-clinical operations. The Director is accountable for ensuring all Utilization Management activities are performed accurately, timely, professionally, and in compliance with CMS, Texas Department of Insurance, NCQA, URAC, delegated health plan, contractual, accreditation, and organizational requirements.
Serves as the primary departmental subject matter expert for all clinical, administrative, regulatory, operational, policy, reporting, universe, audit, and delegation-related Utilization Management requirements. The Director is expected to independently maintain sufficient knowledge of all areas within Utilization Management to provide authoritative interpretation, direction, approval, and oversight without relying on managers, supervisors, staff, or other departments to perform the Director's core responsibilities or serve as the primary subject matter expert on behalf of the department.
Maintains direct accountability for the review, interpretation, implementation, and approval of all regulatory bodies and payer technical specifications applicable to Utilization Management, including the review, validation, reconciliation, sign-off, and approval of all Utilization Management universes and related regulatory submissions. Ensures reporting methodologies, data definitions, inclusion and exclusion criteria, source-system logic, and submission requirements are understood, documented, and applied consistently.
Maintains sole departmental ownership and accountability for the development, professional drafting, review, revision, approval coordination, implementation, and ongoing maintenance of all Utilization Management policies, including clinical and administrative policies. The Director is responsible for ensuring all policies are current, accurate, operationally complete, regulatory compliant, professionally written, approved through the appropriate governance process, loaded into PolicyTech, and maintained within PolicyTech throughout the policy lifecycle. The existing Director description already places responsibility for regulatory standards, management reporting, clinical data, audits, and departmental operations at the Director level; these updates make that ownership more explicit and directly accountable
You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Required Qualifications:- Bachelor's Degree
- Active Texas Registered Nurse (RN) license or valid multistate compact RN license.
- 10+ years of experience in managed care health insurance field, with 5 years in management capacity
- Experience analyzing complex regulations, government contract requirements, and policies and procedures
Preferred Qualifications:- Master's degree
- 3+ years of experience government program managed care/corporate compliance
Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700 - $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.
