Strategic Utilization Management & Analytics Lead

Teacher Retirement System of Texas

Austin (TX)

On-site

USD 108,000 - 150,000

Full time

6 days ago

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Job summary

Teacher Retirement System of Texas seeks a Clinical Utilization Management & Analytics Specialist to lead utilization management oversight, develop clinical programs, and build analytics dashboards that drive cost containment and high‑quality care for Texas educators and retirees.

Requires 5 years in clinical practice or health plan analytics, licensure in a clinical discipline, and proven ability to translate data into policy, vendor oversight, and contract requirements to support procurement

Qualifications

Bachelor’s degree in nursing, medicine, pharmacy, healthcare administration, health informatics, data analytics, public health, or a closely related field; or a professional degree required by licensure.
Five (5) years of progressively responsible experience in clinical practice, provider or health plan utilization management, or healthcare analytics.
Two (2) years of experience in utilization management, prior authorization, healthcare quality, provider operations, health plan operations, or related clinical review activities, including provider-health plan coordination.
Experience reviewing medical records and applying clinical criteria to healthcare services.
A master’s degree or doctoral degree in a closely related field may be substituted on an equivalent year-for-year basis.

Responsibilities

Monitors and improves the health plan administrator’s utilization management operations, including prior authorization, concurrent and retrospective review, case management, appeals, and transitions of care.
Designs custom utilization management requirements, clinical protocols, and performance expectations, and assesses adherence to established criteria and industry standards.
Evaluates vendor performance and recommends actions to reduce waste, improve affordability and outcomes, and preserve access to medically necessary care.
Serves as a primary clinical and analytic resource for utilization management contract oversight, including prior authorization, medical necessity criteria, peer‑to‑peer review, site‑of‑care optimization, exception management, and escalated clinical issues.
Collaborates with TRS leadership, consultants, and health plan administrators to design and implement custom utilization management requirements and clinical programs.
Collaborates with health plan administrators to operationalize approved utilization management changes and ensure consistent implementation.
Evaluates proposed utilization management policies, clinical criteria, and program enhancements for alignment with TRS objectives.
Develops evidence‑based initiatives that reduce unnecessary high‑cost care and promote appropriate lower‑cost settings and less‑invasive, high‑quality alternatives.
Assists with developing contract requirements, performance standards, and clinical program specifications during procurements and contract amendments.
Coordinates implementation activities related to new utilization management initiatives, clinical programs, and regulatory changes.
Analyzes utilization management, prior authorization, site‑of‑care, claims, outcomes, and provider data to identify cost drivers, avoidable utilization, low‑value care, variation, clinically appropriate alternatives, and opportunities to improve quality and total cost of care.
Evaluates proposed programs for their effects on quality, access, site‑of‑care, member experience, and total cost.
Develops reports, dashboards, business cases, and recommendations that quantify opportunities and measure cost, utilization, quality, and outcomes.
Provides clinical expertise for policy development, vendor management activities, audits, procurements, and special projects.
Performs related work as assigned.