Manager of Utilization Management - The Health Plan

 
Position: Manager of Utilization Management - The Health Plan

Job ID: 156114

Location: US-TX-Bellaire

Department: UTILIZATION MGMT - ADMIN

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.  We are an Integrated Community System providing holistic care that empowers families to live healthier lives.  Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

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 the processes and procedures for Utilization Management intake, concurrent review and processing of denial and appeals. This role also assesses the quality of service of Utilization Management and all programs and processes.

 

Think you’ve got what it takes?



Responsibilities :

  • Monitors and audits turnaround time, reviews weekly statistics, ensures quarterly audit activity completed as indicated in policy and procedure
  • Reviews productivity reports and correlates with quality findings
  • Collaborates 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
  • Responsible for implementing the necessary revisions for internal processes and procedures to meet and satisfy all guidelines as indicated by outside auditors
  • Collaborates 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
  • Develops reporting to provides accurate statistics for internal and external review including NCQA studies and TDI licensure reporting
  • Participates in interdepartmental teams to represent Utilization Management needs and processes including claims, network development, finance, quality and outcomes management, provider relations, and member services


Qualifications:

  • Bachelor’s degree in nursing required
  • RN license from the Texas Board of Nursing or Nursing Licensure Compact required
  • 5 years clinical and/or managed care experience required
  • Pediatrics experience preferred
  • Managed Care experience preferred


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