OverviewThe Manager, Utilization Review Nursing is responsible for the operational oversight and leadership of Sendero Health Plans’ Utilization Review Nursing team. This position ensures timely, accurate, and compliant utilization review processes in accordance with applicable state and federal regulations, accreditation standards, clinical guidelines, and organizational requirements.
The Manager provides day-to-day leadership and development of the Utilization Review Nursing team, oversees utilization management policies, procedures, and workflows, monitors operational performance, and supports continuous improvement within the Utilization Management program. The role requires knowledge of health plan operations and multiple lines of business, including HMO, Commercial, Medicare, Medicaid, and Self-Funded plans.
Responsibilities
Essential Functions
- Manage the day-to-day operations of the Utilization Review Nursing team, ensuring timely, accurate, and compliant utilization review activities.
- Provide leadership, guidance, coaching, performance management, and professional development to Utilization Review Nursing team members.
- Support recruitment, selection, onboarding, training, staffing coverage, work assignments, and workload management for the Utilization Review Nursing team.
- Monitor utilization review volumes, turnaround times, quality measures, regulatory requirements, and other operational performance indicators; identify trends and implement process improvements as appropriate.
- Oversee and maintain the Utilization Management Program Description and related policies and procedures in alignment with Texas Department of Insurance (TDI), Centers for Medicare & Medicaid Services (CMS), National
- Committee for Quality Assurance (NCQA), and other applicable regulatory and accreditation requirements.
- Conduct annual policy reviews and updates and ensure utilization review processes align with InterQual Clinical Care Guidelines and applicable Commercial, HMO, Medicare, Medicaid, Self-Funded, and other health plan requirements.
- Develop, write, review, and update standard operating procedures, workflows, and related documentation to support operational efficiency, consistency, and compliance.
- Provide oversight of utilization review activities to support compliance with applicable regulatory, accreditation, contractual, and organizational requirements.
- Support regulatory, accreditation, and audit readiness related to Utilization Management activities and coordinate follow-up on identified findings or corrective actions.
- Serve as an operational escalation resource for complex utilization review matters and coordinate with Medical.
- Management leadership and other appropriate clinical resources when additional clinical review or determination is required.
- Manage the department budget, including payroll oversight and resource allocation, to support operational and organizational objectives.
- Participate in rotational weekend and holiday on-call coverage as required to support Utilization Management operations.
Knowledge, Skills and Abilities:
- Extensive knowledge of utilization management principles, practices, processes, and health plan operations.
- Knowledge of HMO, Commercial, Medicare, Medicaid, and Self-Funded lines of business.
- Knowledge of Texas Department of Insurance requirements applicable to health plan utilization management and operations.
- Knowledge of CMS regulations and requirements applicable to utilization management and health plan operations.
- Knowledge of NCQA accreditation standards and requirements.
- Knowledge and experience applying InterQual Clinical Care Guidelines or comparable evidence-based clinical criteria.
- Knowledge of Commercial insurance policies, processes, and regulatory requirements.Knowledge of utilization management policy, procedure, workflow, and program development.
- Ability to interpret regulatory and accreditation requirements and translate them into operational processes.
- Ability to monitor operational performance, identify trends, and implement process and quality improvements.
- Strong leadership, coaching, organizational, decision-making, problem-solving, and communication skills.
- Ability to work collaboratively with clinical, operational, compliance, and other internal and external partners.
- Proficiency with Microsoft Office Suite and applicable utilization management, health plan, and electronic clinical systems.
Qualifications
Minimum Education:
- Associates Degree (higher degree accepted) in Nursing, Healthcare Management, Healthcare Administration, or a related healthcare field. Required
Minimum Experience:
- 5 years of utilization management experience within a health plan or health insurance environment, including experience with Texas-regulated health plan operations.
- 1 year of leadership experience within a health plan, utilization management, or related healthcare environment.
Required Licenses and Certifications:
- LPN Current Texas or Compact State license, active and in good standing Upon Hire Required Or
- RN Current Texas or Compact State license, active and in good standing Upon Hire Required
