Utilization Management Senior Manager

Community First Health Plans; San Antonio (TX); On-site; USD 110,000 - 150,000; Full time

Benefits offered by this job

Magnet recognition desirable

Job summary

Community First Health Plans seeks a visionary leader for Utilization Management to guide accreditation readiness, ensure regulatory compliance, and drive performance improvement. This executive role oversees staff, prior authorizations, and review processes.

You will bridge Medical Directors, executive leadership, and regulators, shaping UM strategy and governance to ensure timely determinations and high-quality member care.

Qualifications

• Graduate of an accredited school of professional nursing.
• BSN required; Master's degree preferred.
• Minimum five years in Utilization Management and two years in leadership.
• Knowledge of NCQA/URAC/CMS requirements and Texas Medicaid regulations.
• Experience in managed care or regulated healthcare environments is preferred.

Responsibilities

• Provides strategic leadership for Utilization Management programs and initiatives.
• Oversees accreditation readiness, regulatory compliance, and performance improvement planning.
• Leads staff development, audits, and inter-rater reliability processes.
• Ensures medical necessity criteria and policies are consistently applied.
• Collaborates with Medical Directors, Care Management, Compliance, and Quality teams.

Skills

Leadership

Regulatory knowledge

Utilization Management

Quality improvement

Staff development

Education

Bachelor's in Nursing (BSN)

Master's degree (preferred)

RN license (Texas)

Tools

InterQual

MCG

Job description

POSITION SUMMARY/RESPONSIBILITIES

Provides strategic leadership for Utilization Management programs and initiatives. Responsible for accreditation readiness, regulatory compliance oversight, performance improvement planning, delegated oversight, operational governance, and implementation of organizational UM strategies. Serves as a liaison between operational leadership, Medical Directors, executive leadership, regulatory agencies, and accreditation organizations.

Provides leadership, oversight, direction, and performance management for Utilization Management staff, including clinical reviewers, denial and appeals staff, and administrative personnel. Oversees utilization review operations, prior authorization activities, concurrent review, retrospective review, appeals support, and regulatory compliance activities. Ensures consistent application of medical necessity criteria, regulatory requirements, accreditation standards, and organizational policies. Leads quality improvement initiatives, audit readiness activities, inter-rater reliability processes, staff development, and operational performance monitoring. Collaborates with Medical Directors, Care Management, Provider Relations, Compliance, Quality Management, and other departments to ensure appropriate utilization of healthcare resources, timely determinations, regulatory compliance, and member-centered care.

EDUCATION/EXPERIENCE

Graduate of an accredited school of professional nursing required. Bachelor's degree in Nursing (BSN). A Master's degree is preferred.

Minimum five (5) years of Utilization Management experience and two (2) years of management or leadership experience are required.

Demonstrated knowledge of:

• NCQA Utilization Management Standards
• URAC Utilization Management Standards
• CMS Managed Care requirements
• Texas Medicaid Managed Care regulations
• Medical necessity review criteria, including InterQual®, MCG®, and/or organization-approved clinical review criteria
• Utilization Management operations, including prior authorization, concurrent review, retrospective review, appeals, and denial management
• Regulatory compliance, accreditation readiness, quality improvement, and performance monitoring

Experience in a managed care organization, health plan, delegated entity, Medicare, Medicaid, or other regulated healthcare environment is preferred.

LICENSURE/ CERTIFICATIONS

Current unrestricted Registered Nurse (RN) license issued by the Texas Board of Nursing is required. A Magnet recognized national certification is highly desirable. Certified Case Manager (CCM), Accredited Case Manager (ACM), Utilization Management Certification, or other related certification is required. If certification is not held at the time of hire, certification may be required within two (2) years of hire or transfer into the position, consistent with organizational requirements.