Utilization Management Director, El Paso Health

El Paso Health; El Paso (TX); On-site; USD 80,000 - 110,000; Full time

Job summary

El Paso Health is seeking a leader for its Utilization Management program in El Paso, Texas. The ideal candidate will have at least five years in management, with a solid understanding of Medicaid and government programs. This role is crucial for ensuring compliance and effective administration of health plan benefits.

Key responsibilities include strategic oversight and partnership with healthcare providers, critical for the development and maintenance of utilization management protocols.

Apply now to join a committed team dedicated to improving quality of care.

Qualifications

• Five years of experience in a management/supervisory capacity.
• Strong background in managed care environment.
• Experience with utilization review and clinic operations.

Responsibilities

• Provide strategic leadership for the Utilization Management program.
• Ensure compliance with regulatory requirements.
• Partner with healthcare providers for plan benefits administration.

Skills

Leadership

Communication

Analytical skills

Negotiation

Organization

Interpersonal skills

Microsoft Excel

Microsoft PowerPoint

Microsoft Word

Education

Current and active Registered Nurse license in Texas

Job description

• Facility University Medical Center of El Paso
• Department EPH Health Services
• Schedule - Shift - Hours Full Time - Days - 8A-5P

Provides strategic leadership and oversight of El Paso Health’s Utilization Management (UM) program, including planning, development, implementation, and continuous quality improvement of integrated UM services across all lines of business. Ensures compliance with all contractual, regulatory, and accreditation requirements established by HHSC, TDI, CMS, URAC, and other governing bodies.

Partners with healthcare providers to ensure appropriate and consistent administration of plan benefits through clinical review processes, including prior authorization, medical necessity determinations, out-of-network requests, and appropriate level-of-care decisions. Applies medical policies, clinical guidelines, benefit structures, and standardized decision-support tools within scope of licensure. Develops and maintains utilization management protocols supporting Medicaid, CHIP, Medicare Advantage, and Third-Party Administrator products. Maintains an effective and informed relationship with health plan Medical Director(s).

Work Experience

Five years of experience in a management/supervisory capacity required. Strong background in managed care environment with Medicaid and/or other government programs is optimal. Experience with utilization review, clinic operations, and data collection and analysis preferred. Familiarity with third party insurance and other forms of reimbursement preferred.

License/Registration/Certification

Current and active license to practice as a Registered Nurse in the state of Texas required.

Skills

• Proven leadership, communication, and interpersonal skills necessary to interact effectively with physicians, management, associates, and external agencies/customers.
• Solid organization and contract management skills.
• Excellent analytical and negotiation skills.
• Excellent oral and written communication, interpersonal and time management skills.
• Ability to execute and be a self-starter and follow through on projects.
• Possess expertise in Microsoft Excel, Power Point and Microsoft Word.
• Strong computer skills, including familiarity with database systems.

1145 Westmoreland Drive
El Paso, TX 79925-5615