Director, Utilization Management, RN - Hybrid - Kelsey Seybold Clinics

Optum; Pearland (TX); On-site; USD 113,000 - 193,000; Full time

Job summary

Kelsey-Seybold Clinic, part of the Optum family, seeks a Director of Utilization Management to oversee inpatient/outpatient reviews, medical necessity determinations, and regulatory compliance across CMS, Texas TDI, NCQA, URAC, and payer requirements.

This leadership role requires RN licensure, 10+ years in managed care with 5+ in management, and strong analytical and policy skills to drive quality, efficiency, and cost containment.

Qualifications

• RN licensure required (Texas RN or multi-state compact)
• 10+ years in managed care health insurance field, with 5+ years in management
• Experience analyzing complex regulations, government contract requirements, and policies and procedures

Responsibilities

• Oversee inpatient and outpatient utilization management functions
• Ensure compliance with CMS, Texas Department of Insurance, NCQA, URAC, and payer requirements
• Provide subject-matter expertise on regulatory submissions, universes, and policy development
• Lead policy development, governance, and quality improvement initiatives

Skills

RN licensure

Leadership experience

Regulatory analysis

Managed care expertise

Education

Bachelor's Degree

Master's degree

Job description

Explore opportunities with Kelsey-Seybold Clinic, part of the Optum family of businesses. Work with one of the nation's leading health care organizations and build your career at one of our 40+ locations throughout Houston. Be part of a team that is nationally recognized for delivering coordinated and accountable care. As a multi-specialty clinic, we offer care from more than 900 medical providers in 65 medical specialties. Take on a rewarding opportunity to help drive higher quality, higher patient satisfaction and lower total costs. Join us and discover the meaning behind Caring. Connecting. Growing together.

Provides executive leadership, strategic direction, and comprehensive operational oversight for all Utilization Management functions, including inpatient utilization review, outpatient prior authorization, concurrent review, retrospective review, medical necessity determination, physician review processes, administrative utilization support, delegated health plan requirements, regulatory reporting, and related clinical and non-clinical operations. The Director is accountable for ensuring all Utilization Management activities are performed accurately, timely, professionally, and in compliance with CMS, Texas Department of Insurance, NCQA, URAC, delegated health plan, contractual, accreditation, and organizational requirements.

Serves as the primary departmental subject matter expert for all clinical, administrative, regulatory, operational, policy, reporting, universe, audit, and delegation-related Utilization Management requirements. The Director is expected to independently maintain sufficient knowledge of all areas within Utilization Management to provide authoritative interpretation, direction, approval, and oversight without relying on managers, supervisors, staff, or other departments to perform the Director's core responsibilities or serve as the primary subject matter expert on behalf of the department.

Maintains direct accountability for the review, interpretation, implementation, and approval of all regulatory bodies and payer technical specifications applicable to Utilization Management, including the review, validation, reconciliation, sign-off, and approval of all Utilization Management universes and related regulatory submissions. Ensures reporting methodologies, data definitions, inclusion and exclusion criteria, source-system logic, and submission requirements are understood, documented, and applied consistently.

Maintains sole departmental ownership and accountability for the development, professional drafting, review, revision, approval coordination, implementation, and ongoing maintenance of all Utilization Management policies, including clinical and administrative policies. The Director is responsible for ensuring all policies are current, accurate, operationally complete, regulatory compliant, professionally written, approved through the appropriate governance process, loaded into PolicyTech, and maintained within PolicyTech throughout the policy lifecycle. The existing Director description already places responsibility for regulatory standards, management reporting, clinical data, audits, and departmental operations at the Director level; these updates make that ownership more explicit and directly accountable.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• Bachelor's Degree
• Active Texas Registered Nurse (RN) license or valid multistate compact RN license.
• 10+ years of experience in managed care health insurance field, with 5 years in management capacity
• Experience analyzing complex regulations, government contract requirements, and policies and procedures

Preferred Qualifications:

• Master's degree
• 3+ years of experience government program managed care/corporate compliance

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you'll find a far-reaching choice of benefits and incentives. The salary for this role will range from $112,700 - $193,200 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

OptumCare is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

OptumCare is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.