Utilization Review / Concurrent Nurse Manager (REMOTE IN TEXAS ONLY)

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

Job summary

A leading healthcare organization is seeking an experienced Utilization Management Manager for their Texas health plan. This fully remote role entails supervising the utilization review nursing team, assuring compliance with regulations, and fostering professional growth within a supportive environment. Candidates must have an active Texas nursing license and a strong background in health plan management.

Benefits

Competitive salary and benefits package

Flexible remote working environment

Opportunities for professional growth and development

Qualifications

• 5+ years in health plan utilization management required.
• At least 1 year in a health plan leadership role.
• Active Texas nursing license in good standing required.

Responsibilities

• Supervise the Utilization Review Nursing team for accuracy.
• Conduct annual policy reviews and maintain compliance.
• Manage department budget and resource allocation.

Skills

Leadership

Communication

Organization

Education

Bachelor's Degree in Science of Nursing

Advanced Degree (preferred)

Tools

Microsoft Office Suite

Electronic Medical Record (EMR) systems

Job description

Overview

Sendero Health Plan seeking an experienced and motivated Utilization Management Manager to lead and oversee the utilization review nursing team for our Texas health plan. This role ensures compliance with state and federal regulations, maintains operational efficiency, and supports organizational goals. The position is fully remote but requires residency in Texas and an active Texas nursing license in good standing. Benefits: Competitive salary and benefits package with flexible remote working environment within Texas and opportunities for professional growth and development.

Working hours: Monday through Friday, 8am - 5 pm and On-call hours: Saturday, Sunday, and Holidays, 9 am to 12 pm on a rotational basis.

Responsibilities

Essential Functions

• Supervise and provide guidance to the Utilization Review (UR) Nursing team, ensuring timely and accurate reviews.
• Foster professional development, performance evaluations, and continuous improvement initiatives.
• Oversee and maintain the Utilization Management Program Description, ensuring alignment with Texas
• Department of Insurance (TDI), CMS guidelines, and NCQA accreditation standards
• Conduct annual policy reviews, updates, and ensure adherence to InterQual Clinical Care Guidelines and
• Commercial insurance regulations.
• Develop, write, and update Standard Operating Procedures (SOPs) to enhance operational efficiency and compliance.
• Manage the department budget, including payroll oversight and resource allocation to support business objectives.
• Participate in on-call duties during weekends and holidays (Saturday and Sunday, 9 am - 12 pm) on rotational basis.

Knowledge, Skills and Abilities:

• Extensive knowledge of State Health Plan Regulatory Guidelines
• Knowledge of NCQA Accreditation Standards
• Knowledge and experience using InterQual Clinical Care Guidelines
• Knowledge and experience working with Commercial Insurance
• Strong organization, leadership, and communication skills
• Knowledge of Commercial insurance policy and process development
• Proficient in Microsoft Office Suite and electronic medical record (EMR) systems

Qualifications

Minimum Education: Bachelor's Degree in Science of Nursing or related field required; advanced degree preffered

Minimum Experience:

• 5 years Minimum experience in health plan utilization management Required and
• 1 year At least 1 year in a health plan leadership role Required

Required License: RN - Registered Nurse - State Licensure and/or Compact State Licensure; Texas or Compact State - in good standing and active Upon Hire