Utilization Management Director, El Paso Health

Summary Job Summary 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 relatio...