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

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

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