Director, Utilization Management - CMC - Clear Lake Center

UTMB Health; Galveston (TX); On-site; USD 120,000 - 190,000; Full time

Job summary

UTMB Health is seeking a Director of Utilization Management for the Correctional Managed Care Center in Galveston, TX. The role leads the Utilization Management Program serving inmate populations under TDCJ and TJJD, coordinating review, case management, and reporting.

The candidate will guide QA/QI initiatives, manage staff, and partner with medical and security teams to optimize care delivery and resource use within a correctional setting. A master's degree and RN license are required.

Qualifications

• Master's degree in a related field plus five years of progressive leadership and clinical experience in healthcare, including utilization management.
• Graduate of accredited Registered Nursing program with current unrestricted Texas RN license.
• Experience leading utilization management, case management, or managed care in a correctional or large healthcare system.

Responsibilities

• Organize a staff to perform Utilization Review and Case Management within Utilization Management.
• Oversee staff orientation to Utilization Management methods and documentation.
• Serve as a resource to medical and security personnel at prison level for managed care processes.
• Oversee ongoing quality assurance and quality improvement for Utilization Management.
• Develop and maintain reporting and documentation for the Utilization Management Program.
• Evaluate and modify the Utilization Management program over time.
• Ensure 24-hour operation of the department to serve CMC patients.
• Ensure fiscal responsible use of resources and adherence to internal controls.

Skills

Data analysis

Performance improvement

Adaptability

People skills

Prioritization

Education

Master's degree in related field

RN license (unrestricted, Texas)

Tools

InterQual

Healthcare analytics platforms

Job description

Director, Utilization Management - CMC - Clear Lake Center

Galveston, Texas, United States

Executive - Correctional Managed Care

UTMB Health

Requisition # 2604873

Summary:

The Director is responsible for the coordination and management of a full-service Utilization Management program to service the TDCJ, TJJD and other contracted inmate populations.

The mission of Correctional Managed Care is to address the healthcare needs of underserved patient populations within the Texas Department of Criminal Justice (TDCJ) and the Texas Juvenile Justice Department (TJJD).

Scope:

Contribute to the success of UTMB and the (CMC) Correctional Managed Care Organization through the effective management of the CMC Utilization Management Program. May be required to work within the confines of a prison, jail, or juvenile detention center.

Responsibilities:

• Organize a staff of professionals to perform all aspects of both Utilization Review and Case Management in the Utilization Management Program.
• Oversee the orientation program of staff to the Utilization Management methods, review, and the documentation process.
• Acts as a resource to medical and security personnel at the prison level to the managed care process.
• Oversee an ongoing quality assurance/ quality improvement program for the Utilization Management Department.
• Responsible for the development of all the reporting and documentation needs for the Utilization Management Program.
• Develop and maintain an ongoing process to evaluate and modify the Utilization Management program.
• Continuous monitoring and improvement of reporting and documents to reflect the department's productivity, patient population and opportunities for improvement and predictive analysis.
• Responsible for the twenty-four-hour operation of the department to provide services to the CMC patient population.
• Ensure effective fiscal responsible use of resources.
• Adheres to internal controls and reporting structure established for department.
• Performs other related duties as required.

Knowledge, Skills & Abilities:

• Strong data analysis skills
• Performance Improvement expertise
• Flexible and adept at managing a changing work environment
• Superior people skills to interact with varied agencies, departments, and healthcare providers
• Outstanding prioritization and organizational skills

Minimum Qualifications:

• Master's Degree in related field plus five (5) years of progressive leadership and clinical experience in a healthcare environment to include four (4) years of utilization management experience.
• Graduate of accredited Registered Nursing program with current unrestricted Texas RN License.

Preferred Qualifications:

• Master's degree in Nursing, Healthcare Administration, Business Administration, Public Health, or related field plus five (5) or more years of progressive leadership experience in utilization management, case management, managed care, or healthcare operations in a correctional healthcare, academic medical center or large integrated healthcare system environment.
• Current CCM, ACM, CPHQ, or equivalent utilization management/quality certification.
• Advanced experience with InterQual and healthcare analytics platforms.
• Demonstrated expertise in performance improvement, physician engagement, and utilization optimization initiatives.
• Lean Six Sigma certification.
• Proven success leading large multidisciplinary teams and complex healthcare operations.
• Certification for performance improvement.

Equal Employment Opportunity

UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a Federal Contractor, UTMB Health takes affirmative action to hire and advance protected veterans and individuals with disabilities.

Compensation