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Manager Optum Utilization Review Jobs in Spring, TX

Harris Health System

Sr Mgr-Utilization Mgmt

Houston, TX · On-site

$107.60K - $134.50K/yr

May oversee complex case management, concurrent review, prior authorization, call center and or ... Understand the Utilization Review process including census management. Experienced with medical ...

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$81K

$149.1K

How much do manager optum utilization review jobs pay per year?

As of May 29, 2026, the average yearly pay for manager optum utilization review in Spring, TX is $80,990.00, according to ZipRecruiter salary data. Most workers in this role earn between $52,900.00 and $97,400.00 per year, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Manager, Optum Utilization Review, and why are they important?

To thrive as a Manager, Optum Utilization Review, you need a background in healthcare management, clinical expertise (often as an RN or related field), and experience with utilization management processes. Familiarity with utilization review software, electronic health records (EHRs), and relevant certifications such as CCM (Certified Case Manager) or URAC accreditation is typically required. Strong leadership, analytical thinking, and effective communication skills help you guide teams and collaborate with providers and payers. These competencies are crucial for ensuring compliance, optimizing patient care, and achieving organizational goals in a complex healthcare environment.

How does a Manager in Optum Utilization Review typically collaborate with clinical and non-clinical teams to ensure effective case management?

As a Manager in Optum Utilization Review, you will regularly coordinate with clinical teams such as nurses, physicians, and case managers to review patient cases for medical necessity and compliance with policies. You’ll also work closely with non-clinical staff, including data analysts and administrative professionals, to streamline workflows and support accurate documentation. Effective collaboration ensures timely decision-making, helps resolve escalated cases, and supports continuous quality improvement initiatives. This role often requires strong communication and leadership skills to align multidisciplinary teams and achieve organizational goals.

What does a Manager of Optum Utilization Review do?

A Manager of Optum Utilization Review oversees a team responsible for evaluating the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They ensure that all reviews comply with regulatory standards, company policies, and clinical guidelines. Managers also collaborate with healthcare providers, monitor team performance, and help implement process improvements to optimize patient outcomes and resource use. Their role is vital in balancing quality patient care with cost-effective service delivery.

What is the difference between Manager Optum Utilization Review vs Utilization Review Nurse?

AspectManager Optum Utilization ReviewUtilization Review Nurse
CredentialsTypically requires a nursing license, certifications in case management or utilization reviewRegistered Nurse (RN) license, certifications in case management or utilization review
Work EnvironmentSupervises teams, manages review processes, collaborates with healthcare providersConducts patient reviews, assesses medical necessity, documents findings
Employer & Industry UsageCommon in health insurance companies, managed care organizations, healthcare providersPrimarily in hospitals, insurance companies, healthcare organizations

The main difference is that the Manager Optum Utilization Review oversees the review process and team management, while the Utilization Review Nurse focuses on conducting individual patient assessments and reviews. Both roles require nursing credentials and knowledge of healthcare policies, but the manager has additional responsibilities in leadership and process oversight.

What are the most commonly searched types of Optum Utilization Review jobs in Spring, TX? The most popular types of Optum Utilization Review jobs in Spring, TX are:
What are popular job titles related to Manager Optum Utilization Review jobs in Spring, TX? For Manager Optum Utilization Review jobs in Spring, TX, the most frequently searched job titles are:
What job categories do people searching Manager Optum Utilization Review jobs in Spring, TX look for? The top searched job categories for Manager Optum Utilization Review jobs in Spring, TX are:
What cities near Spring, TX are hiring for Manager Optum Utilization Review jobs? Cities near Spring, TX with the most Manager Optum Utilization Review job openings:
Manager Optum Utilization Review jobs near you
Utilization Review Nurse

Utilization Review Nurse

Houston Methodist The Woodlands Hospital

The Woodlands, TX

Full-time

Posted 26 days ago

Houston Methodist rating

8.2

Company rating: 8.2 out of 10

Based on 290 frontline employees who took The Breakroom Quiz

56th of 864 rated healthcare providers

Job description

Full Time, Days, Not a Remote position.
Hours: 8:30-5:30, Monday - Friday
At Houston Methodist, the Utilization Review Nurse (URN) position is a licensed registered nurse (RN) who comprehensively conducts point of entry and concurrent medical record review for medical necessity and level of care using nationally recognized acute care indicators and criteria as approved by medical staff, payer guidelines, CMS, and other state agencies. This position prospectively or concurrently determines the appropriateness of inpatient or observation services following review of relevant medical documentation, medical guidelines, and insurance benefits and communicates information to payers in accordance with contractual obligations. The URN position serves as a resource to the physicians and provides education and information on resource utilization and national and local coverage determinations (LCDs & NCDs). This position collaborates with case management in the development and implementation of the plan of care and ensures prompt notification of any denials to the appropriate case manager, denials, and pre-bill team members, as well as management.
FLSA STATUS
Exempt
QUALIFICATIONS
EDUCATION
  • Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
  • Bachelor’s degree preferred

EXPERIENCE
  • Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required
  • RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

SKILLS AND ABILITIES
  • Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
  • Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
  • Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
  • Progressive knowledge of InterQual Level of Care Criteria or Milliman Care Guidelines and knowledge of local and national coverage determinations
  • Recent work experience in a hospital or insurance company providing utilization review services
  • Knowledge of Medicare, Medicaid, and Managed Care requirements
  • Progressive knowledge of community resources, health care financial and payer requirements/issues, and eligibility for state, local, and federal programs
  • Progressive knowledge of utilization management, case management, performance improvement, and managed care reimbursement
  • Ability to work independently and exercise sound judgment in interactions with physicians, payers, and health care team members
  • Strong assessment, organizational, and problem-solving skills
  • Maintains level of professional contributions as defined in Career Path program
  • Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN), Ambulatory Benefit Notice (ABN), Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and Condition Code 44 (CC44)

ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
  • Establishes and maintains effective professional working relationships with patients, families, interdisciplinary team members, payers, and external case managers; listens and responds to the ideas of others.
  • Collaborates with the access management team to ensure accurate and complete clinical and payer information. Educates members of the patient’s healthcare team on the appropriate access to and use of various levels of care.
  • Contributes towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS
  • Pro-actively participates as a member of the interdisciplinary clinical team to confirm appropriateness of the treatment plan relative to the patient’s preference, reason for admission, and availability of resources. Participates in daily Care Coordination Rounds and identifies and communicates barriers to efficient utilization.
  • Reviews H&Ps and admitting orders of all direct, transfer, and emergency care patients designated for admission to ensure compliance with CMS guidelines regarding appropriateness of level of care.
  • Identifies potentially unnecessary services and care delivery settings and recommends alternatives, if appropriate, by analyzing clinical protocols.
  • Escalates appropriate cases to the Physician Advisor (or services) for appropriate second level review, peer-peer discussions, and payer denial- appeal needs. Consults with physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.

QUALITY/SAFETY ESSENTIAL FUNCTIONS
  • Participates in quality improvement activities as stewards for resource utilization as it pertains to medical necessity and level of care. Promotes medical documentation that accurately reflects intensity of services, quality and safety indicators and patient’s need to continue stay.
  • Promotes the use of evidence-based protocols and/or order sets to influence high-quality and cost-effective care. Identifies areas for improvement based on an understanding of evidence-based practice/performance improvement projects based on these observations.
  • Identifies and records episodes of preventable delays or avoidable days due to failure of the progression of the care process

FINANCE ESSENTIAL FUNCTIONS
  • Contributes to meeting department financial targets, with a focus on appropriate utilization and denial prevention. Utilizes resources with cost effectiveness and value creation in mind. Self-motivated to independently manage time effectively and prioritize daily tasks, assisting coworkers as needed.
  • Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care, and program compliance using evidence-based, nationally recognized guidelines. Manages assigned patients and communicates and collaborates with the case manager to assist with appropriate interventions to avoid denial of payment.
  • Collaborates with the revenue cycle regarding any claim issues or concerns that may require clinical review during the pre-bill, audit, or appeal process.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS
  • Identifies and presents areas for improvement in patient care or department operations and offers solutions by participating in department projects and activities.
  • Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an ongoing basis.

SUPPLEMENTAL REQUIREMENTS
    WORK ATTIRE
    • Uniform: No
    • Scrubs: No
    • Business professional: Yes
    • Other (department approved): No

    ON-CALL*
    *Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
    • On Call* Yes

    TRAVEL**
    **Travel specifications may vary by department**
    • May require travel within the Houston Metropolitan area Yes
    • May require travel outside Houston Metropolitan area No
QUALIFICATIONS
EDUCATION
  • Graduate of education program approved by the credentialing body for the required credential(s) indicated below in the Certifications, Licenses and Registrations section
  • Bachelor’s degree preferred

EXPERIENCE
  • Three years of hospital clinical nursing experience

LICENSES AND CERTIFICATIONS
Required
  • RN - Registered Nurse - Texas State Licensure - Texas Board of Nursing_PSV Compact Licensure – Must obtain permanent Texas license within 60 days (if establishing Texas residency)

Company Profile:

Houston Methodist The Woodlands Hospital opened in June 2017. This 725,000-square-foot, full-service, acute-care hospital offers many of the same services as our flagship hospital in the Texas Medical Center. Also, on the beautiful hospital campus, located at the intersection of Interstate 45 and Texas State Highway 242, are two medical office buildings, which include a Breast Care Center; Cancer Center; infusion center; heart and vascular services; neurology; orthopedics and sports medicine; rehabilitation services; wellness services; an outpatient laboratory; and several other multispecialty physician practices. In January 2022, Houston Methodist The Woodlands opened Healing Tower — a $250 million expansion project that added 106 beds, focused on medical-surgical and women’s services, and provided nine operating rooms. The project also included the expansion of the endoscopy center, emergency department and diagnostic imaging department with an enhanced neurodiagnostic and interventional center.

Houston Methodist is an Equal Opportunity Employer.

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