Strategic RN Director, Utilization Management

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

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.