Summary Job Summary Provides strategic leadership and oversight of El Paso Health's Utilization Management (UM) program, including planning, development, implementation, and continuous quality improvement of integrated UM services across all lines of business. Ensures compliance with all contractual, regulatory, and accreditation requirements established by HHSC, TDI, CMS, URAC, and other governing bodies. Partners with healthcare providers to ensure appropriate and consistent administration of plan benefits through clinical review processes, including prior authorization, medical necessity determinations, out-of-network requests, and appropriate level-of-care decisions. Applies medical policies, clinical guidelines, benefit structures, and standardized decision-support tools within scope of licensure. Develops and maintains utilization management protocols supporting Medicaid, CHIP, Medicare Advantage, and Third-Party Administrator products. Maintains an effective and informed relationship with health plan Medical Director(s). Minimum Job Requirements: Work Experience: Five years of experience in a management/supervisory capacity required. Strong background in managed care environment with Medicaid and/or other government programs is optimal. Experience with utilization review, clinic operations, and data collection and analysis preferred. Familiarity with third party insurance and other forms of reimbursement preferred. License/Registration/Certification: Current and active license to practice as a Registered Nurse in the state of Texas required. Education and Training: Bachelor degree in Nursing required. Skills: Proven leadership, communication, and interpersonal skills necessary to interact effectively with physicians, management, associates, and external agencies/customers. Solid organization and contract management skills. Excellent analytical and negotiation skills. Excellent oral and written communication, interpersonal and time management skills. Ability to execute and be a self-starter and follow through on projects. Possess expertise in Microsoft Excel, Power Point and Microsoft Word. Strong computer skills, including familiarity with database systems.
Not specified in the original listing.
Not specified in the original listing.
