Utilization Review Nurse Manager

Join the Texas Health and Human Services Commission (HHSC) and be part of a team committed to creating a positive impact in the lives of fellow Texans. At HHSC, your contributions matter, and we support you at each stage of your life and work journey. Our comprehensive benefits package includes 100% paid employee health insurance for full-time eligible employees, a defined benefit pension plan, generous time off benefits, numerous opportunities for career advancement and more. Explore more details on the Benefits of Working at HHS webpage.

Functional Title: Utilization Review Nurse Manager 
Job Title: Manager IV 
Agency: Health & Human Services Comm 
Department: UR Management Support 
Posting Number: 11035 
Closing Date: 11/24/2025 
Posting Audience: Internal and External 
Occupational Category: Healthcare Practitioners and Technical 
Salary Group: TEXAS-B-25 
Salary Range: $5,797.66 - $9,508.25 
Pay Frequency: Monthly
Shift: Day 
Additional Shift: Days (First) 
Telework: Eligible for Telework 
Travel: Up to 10% 
Regular/Temporary: Regular 
Full Time/Part Time: Full time 
FLSA Exempt/Non-Exempt: Exempt 
Facility Location:  
Job Location City: PARIS 
Job Location Address: 1460 19TH ST NW 
Other Locations:  
MOS Codes: 0203,0207,0302,0520,0602,0802,1802,5502,6302,6502,7202,7208,7210,7220,111X,112X,113X,114X,16GX,41AX 
611X,612X,631X,632X,641X,648X,86M0,86P0,8U000,9G100,SEI15 
 
 

Brief Job Description:

Under the general supervision of the Director for the Long-Term Services and Supports (LTSS) Utilization Review (UR) team, the LTSS UR Manager IV  performs highly advanced (senior level) managerial work administering the daily operations and activities of the Health and Human Services (HHSC) Medicaid Managed Care LTSS Regional units.  Work involves oversight of:  establishment of goals and objectives; oversight of development of guidelines, procedures, policies, rules and regulations; developing schedules, priorities, and standards for achieving established goals; coordinating and evaluating business function and department activities; developing and evaluating budget requests; and monitoring budget expenditures.  Plans, assigns, evaluates and supervises the work of the LTSS UR staff. The UR Manager IV identifies processes and review activities which need changing and makes recommendations for improvement; provides consultation and has oversight of the reviews conducted by the nurses; develops and monitors compliance with policies, procedures, rules, laws, standards, correctness of needs assessments, and justification for levels of Medicaid community services. The UR Manager IV oversees the evaluation methods used by UR staff and is directly responsible for overseeing the development of the UR tools. The position has extensive latitude for use of initiative and independent nursing judgement in the oversight of the UR activities for the unit.  Oversee the development, review, revision and implementation of legislation. Analyzes statistical data and evaluation reports and makes recommendations for improvements.  The UR Manager IV has an oversight of the development of UR strategies and tools to assess the appropriateness of services through the managed care service delivery system.  The UR Manager IV will assess utilization review outcomes to determine future areas of activities needed as part of the business plan; and work with other HHSC staff, and managers, to develop in-service training.

Essential Job Functions (EJFs):

 Attends work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned.    

Ability to manage business units, with functions including planning, and assigning work to other unit staff, and providing leadership in the development, coordination, and evaluation of program activities.25%

Oversees, guides and evaluates utilization review staff in the development of program protocols, review procedures, and tools to ensure UR activities are in compliance with agency, state, and federal rules, laws, statutes, and guidelines. 25%

Oversees and evaluates the UR unit functions, recommends solutions for program and process improvement for the unit.  20%

Oversees and evaluates program outcomes through the use of statistical studies, review reports, and quality assurance reports, to improve review processes.15%

Oversees the development of training and technical assistance for unit staff and managed care organizations, and internal divisions related to reviews conducted by unit staff. 10%

Performs visits to various applicable settings for clinical learning experiences.  5%

Knowledge, Skills and Abilities (KSAs):

Knowledge of: Management principles and how to effectively manage a business unit; nurse practice act, health care laws, rules, standards and regulations; quality management; utilization management and review principles and practices; knowledge of the medical necessity and level of care determination for individuals in a home and community based waiver; knowledge of care needs and services for individuals who are aged or disabled; and knowledge of Medicaid managed care.

Skill in:   written and verbal communication, and organization skills necessary to develop and manage staff.  Skill in development of unit policies, rules, and guidelines, to consult, teach, and provide clear and concise direction, and to clearly explain reports resulting from data analysis.

Ability to: identify appropriate services for individuals served; prepare, maintain and present reports; explain and interpret applicable health laws, rules, standards, and regulations; recognize patterns of medical necessity fraud and abuse.  Ability and experience working in cross-functional groups and teams.  Ability to: gather, assemble, correlate, and analyze facts; devise solutions to problems; develop and evaluate policies and procedures.   Ability to use a personal computer, fax machine, copier, telephone conferencing functions, and components of Microsoft Office Suite and Outlook e-mail.   Ability to travel independently throughout the state as necessary.   Ability to plan, assign, and supervise the work of others.

Registrations, Licensure Requirements or Certifications:

Licensed as a Registered Nurse (RN) in the state of Texas, or in a party state, that recognizes reciprocity through the Nurse Licensure Compact.

Initial Screening Criteria:

Minimum three years nursing experience in a clinical setting required.  Experience with at least one of the following: Texas Medicaid, managed care, or utilization review working with Medicaid waiver programs.

Additional Information:

 Information on application must clearly state how applicants meet the initial selection criteria in the Summary of Experience section of the application. Part-time teleworking opportunities available following successful completion of the initial orientation period or in accordance with business needs. 

Review our Tips for Success when applying for jobs at DFPS, DSHS and HHSC.

Active Duty, Military, Reservists, Guardsmen, and Veterans:

Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to those listed in this posting. All active-duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information please see the Texas State Auditor’s Job Descriptions, Military Crosswalk and Military Crosswalk Guide at Texas State Auditor's Office - Job Descriptions.

ADA Accommodations:

In compliance with the Americans with Disabilities Act (ADA), HHSC and DSHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

Pre-Employment Checks and Work Eligibility:

Depending on the program area and position requirements, applicants selected for hire may be required to pass background and other due diligence checks.

HHSC uses E-Verify. You must bring your I-9 documentation with you on your first day of work. Download the I-9 Form

Telework Disclaimer:

This position may be eligible for telework.  Please note, all HHS positions are subject to state and agency telework policies in addition to the discretion of the direct supervisor and business needs.