Director of Utilization Review
On-siteMidland, Texas, United States
Job Summary
Conduct and oversee admission, continued-stay, and discharge reviews using clinical criteria like InterQual or MCG. Manage pre-certifications, concurrent reviews, and peer-to-peer escalations with commercial insurers, Medicare, and Texas Medicaid. Intervene early on potential denials, lead appeal processes, and coordinate with revenue cycle teams. Maintain adherence to Texas Health and Human Services regulations, DNV/ISO standards, and CMS conditions of participation. Work alongside psychiatrists, nursing staff, and social services during daily treatment team meetings to support patient progression and discharge planning. Monitor key metrics including length of stay, denial rates, approval trends, and payer mix. This onsite role operates Monday through Friday from 8:00 AM to 5:00 PM. You will lead operations at a new, free-standing psychiatric hospital in Midland, TX, helping transform access to behavioral health care across West Texas and Southeastern New Mexico.
Required Qualifications
- Current, unencumbered Registered Nurse (RN) license in the State of Texas
- Advanced behavioral health licenses like LCSW or LPC depending on scope
- Minimum of 2 years of psychiatric or behavioral health clinical nursing experience
- 2+ years of specific experience in utilization review, case management, or managed care environments
- Ideally involving Texas Medicare/Medicaid
- Proficiency with evidence-based criteria sets such as InterQual, MCG
- Proficiency with electronic medical record (EMR) systems
- Strong negotiation skills
- Critical thinking skills
- Regulatory compliance tracking skills
- Professional communication abilities
- Onsite position
- Schedule is Monday – Friday from 8:00 AM – 5:00 PM
Desired Qualifications
- Ideally involving Texas Medicare/Medicaid
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