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Professional - Clinical
Manager Utilization Management
Houston, TX, US
We are searching for a Manager Utilization Management- To develop all of the processes and procedures for Utilization Management intake, concurrent review and processing of denial and appeals. Assesses the quality of service of Utilization Management and all programs and processes.
Think you've it what it takes?
Qualifications:
- Bachelor's Degree Nursing Or Master's Degree Speech Language Pathology Or Master's Degree Physical or Occupational Therapy Or Master's Degree Social Work required
- One of the following is required:
- RN - License-Registered Nurses from Texas Board of Nursing or Nursing Licensure Compact
- PT - Physical Therapist Texas Board of Physical or Occupational Therapy Examiners
- OT - Occupational Therapist Texas Board of Physical or Occupational Therapy Examiners
- TX-SLP - Texas Speech Language Pathology American Speech-Language Hearing Association (ASHA)
- LCSW - Lic Clinical Social Worker Texas Behavioral Health Executive Council (TBHEC)
- LMSW - Licensed Master Social Worker Texas Behavioral Health Executive Council
- 3 years Utilization Management Prior Authorization Experience required
- 2 years Managed care experience with government sponsored programs required
- 2 years Pediatrics experience preferred
Responsibilities:
- Oversight and development of the processes and procedures for Utilization Management unit of the health plan.
- Monitors and audits turn around time, reviews weekly statistics, ensures quarterly audit activity completed as indicated in policy and procedure.
- Collaborates with Assistant Director, UM Medical Director or designee in the planning and implementation process to support adherence to regulatory guidelines, NCQA guidelines, TDI regulations, federal and legislative obligations, as well as contractual agreements.
- Collaborates with the Chief Medical Officers, Medical Directors and Associate Medical Directors in the appeals process, including investigating the initial review and documentation for decision making as indicated by policy and procedures.
- Assessment of trends for future opportunity for improvement in utilization management.
- Provides quarterly reporting to HHSC and for the Clinical and Administrative Advisory Committee as assigned.
- Identifies areas of inefficiency and facilitates/coordinates resolution inter/intra departmentally by acting as liaison between departments across the health plan.
- 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.
About Texas Children’s
Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.
To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities.
Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
