Senior Nursing Utilization Review Manager

Santa Barbara Cottage Hospital; United States; Remote; USD 90,000 - 130,000; Full time

Job summary

Sendero Health Plans is seeking a Manager, Utilization Review Nursing to lead the Utilization Review Nursing team, ensuring timely, accurate, and compliant review processes across HMO, Commercial, Medicare, Medicaid, and Self-Funded plans.

You will guide staffing, policy updates, audits, and performance metrics, collaborate with Medical and operations, and ensure readiness for regulatory, accreditation, and InterQual guideline adherence.

Qualifications

• 5 years of utilisation management experience within a health plan or health insurance environment.
• 1 year of leadership experience within a health plan, utilisation management, or related healthcare environment.
• Experience with Texas-regulated health plan operations.

Responsibilities

• Manage the day-to-day operations of the Utilization Review Nursing team, ensuring timely, accurate, and compliant utilization review activities.
• Provide leadership, guidance, coaching, performance management, and professional development to Utilization Review Nursing team members.
• Support recruitment, onboarding, training, staffing coverage, work assignments, and workload management for the Utilization Review Nursing team.
• Monitor utilization review volumes, turnaround times, quality measures, regulatory requirements, and other operational performance indicators; identify trends and implement process improvements as appropriate.
• Oversee policy updates and ensure alignment with NCQA, CMS, TDI, and other requirements.
• Develop, write, review, and update SOPs, workflows, and related documentation to support efficiency and compliance.

Skills

Utilization management

Leadership

Regulatory knowledge

Communication

Education

Associates Degree in Nursing or Healthcare Administration

Tools

Microsoft Office

Clinical systems

Job description

Sendero Health Plans is seeking a Manager, Utilization Review Nursing to lead the Utilization Review Nursing team, ensuring timely, accurate, and compliant review processes across HMO, Commercial, Medicare, Medicaid, and Self-Funded plans.

You will guide staffing, policy updates, audits, and performance metrics, collaborate with Medical and operations, and ensure readiness for regulatory, accreditation, and InterQual guideline adherence.