The Utilization Management Leader oversees clinical and nonclinical team operations, including case management, concurrent review, prior authorization, call center support, and letter review. This role is responsible for team performance, productivity, quality outcomes, regulatory compliance, and staff development.

Key responsibilities include monitoring operational metrics, managing daily staffing needs and workloads, conducting audits, facilitating clinical rounds, supporting onboarding and training, and resolving authorization issues. This leader partners across departments to improve processes, enhance efficiencies, and support organizational goals and member outcomes.

The ideal candidate is a collaborative, solution-oriented leader with strong knowledge of utilization review processes, medical necessity guidelines (MCG and/or InterQual), and managed care operations. This position requires the ability to work independently, manage competing priorities, and perform effectively in a fast-paced environment.

Community employees' benefits are provided by Harris Health. These benefits are designed to provide you with flexibility and options to meet your specific needs.

Community is an Equal Opportunity Employer.

Harris Health's benefits program is designed to provide you with greater flexibility and more choices to meet your specific needs. Harris Health's benefits program allows you to protect your income in case of illness, death, and disability, and to help you save for retirement.

• RN required; BSN preferred
• Current unrestricted Texas RN license required
• MBA, MHA, or MSN preferred
• 3–5 years of managed care experience
• 3–5 years of leadership or supervisory experience
• Experience with Medicaid and/or Commercial lines of business preferred
• Knowledge of utilization review, census management, and medical necessity guidelines required
• CCM certification preferred
• Proficiency in Microsoft Office applications required
• Applicants must reside in Texas

About Community Health Choice

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO) licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 450,000 Members with the following programs: Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization are available to all, regardless of pre-existing conditions. Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more. Improving Members' experiences is at the heart of every Community position.... We strive every day to make sure that our Members have access to the high-quality health care they need and deserve. Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

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Connections working at Community Health Choice