Job Summary
Oversees the day-to-day medical necessity, authorization, and clinical review functions within the Health Services Department, ensuring UR Associates apply established medical policies, clinical guidelines, and plan benefit criteria consistently and within scope of licensure. Coordinates closely with Case Management to support seamless care transitions and with the Pharmacy Department to streamline medication-related authorizations, helping ensure each member receives appropriate, high-quality care in a timely manner. Oversees UR, compliance, and cross-departmental coordination across all health plan lines of business, including Medicaid (STAR, STAR+PLUS), CHIP (CHIP, CHIP Perinate), Medicare and Duals (D-SNP, Medicare Advantage, Medicare Dual Aligned), and Commercial and Specialty lines (Preferred Administrators, HCO). Directly supervises Clinical Reviewers (RNs/LVNs) to ensure timely, accurate, and compliant coverage decisions, and provides oversight to Utilization Review Assistants who assist with workflows, reporting, and the completion of clerical duties related to authorizations.
Skills
1. Excellent oral/written communication skills and exemplary interpersonal skills.
2. Proficient in Microsoft Windows, Word, Excel, and PowerPoint with strong analytical, and data management skills.
3. Proficient in utilization management principles, conflict resolution, creative problem-solving, and/or group facilitation techniques.
4. Demonstrated knowledge of state regulations, compliance standards, and network guidelines; ability to interpret health plan benefits to community providers, manage clinical authorization workflows, and make accurate, data-driven medical necessity decisions.
5. Ability to provide effective, professional support to teams, manage multiple priorities in a fast-paced environment, and oversee the productivity of utilization reviewers.
6. Demonstrates sensitivity to cultural diversity and the ability to work with diverse populations; self-motivated, with a willingness to take responsibility for clinical care.
7. Strong time management skills, with the ability to prioritize activities and complete assignments; ability to interact effectively with supervisors, members, and community providers.
Work Experience
One year of clinical supervisory, lead, or charge nurse experience is required. Experience with utilization review/utilization management within a managed care organization (MCO) environment is preferred. Deep operational knowledge of MCG and InterQual clinical guidelines, CMS regulations, Texas Medicaid rules, HHSC requirements, and TDI regulations is required.
License/Registration/Certification
Active and unrestricted license to practice as a Registered Nurse (RN) in the State of Texas is required.
Education and Training
Bachelor of Science in Nursing (BSN) is required.
