RN Executive – Utilization Management Leader

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 in Pearland, TX. This role provides executive leadership and strategic direction for inpatient and outpatient utilization review, prior authorization, and related regulatory activities.

You will own policies in PolicyTech, oversee reporting and audits, ensure CMS and state regulatory compliance, and act as the department's subject matter expert across clinical, administrative, and contractual requirements.

Qualifications

• Bachelor's Degree required.
• Active Texas RN license or multistate compact RN license.
• 10+ years in managed care health insurance, with 5+ years in management.
• Experience analyzing complex regulations, government contract requirements, and policies/procedures.

Responsibilities

• Provide executive leadership and oversight for Utilization Management, including inpatient/outpatient review, prior authorization, and regulatory compliance.
• Ensure adherence to CMS, Texas Department of Insurance, NCQA, URAC, and contractual requirements; interpret and apply regulatory standards.
• Develop, revise, and maintain UM policies and procedures; oversee policy lifecycle in PolicyTech.
• Oversee reporting, audits, and regulatory submissions; serve as SME across clinical, administrative, and delegated requirements.

Skills

Regulatory analysis

Healthcare leadership

Policy development

Strategic direction

Education

Bachelor's Degree

Master's degree

Job description

Kelsey-Seybold Clinic, part of the Optum family, seeks a Director of Utilization Management in Pearland, TX. This role provides executive leadership and strategic direction for inpatient and outpatient utilization review, prior authorization, and related regulatory activities.

You will own policies in PolicyTech, oversee reporting and audits, ensure CMS and state regulatory compliance, and act as the department's subject matter expert across clinical, administrative, and contractual requirements.